In a society that has these emerging expectations of its health care system, consultant pharmacists are in a particularly awkward ethical position. They may know that drug B or procedure A is indicated for a nursing home resident, or that a new advance in medical therapy would improve the resident's quality of life. Yet pharmaceutical manufacturers have become adept at pricing new drugs at the cost-benefit breaking point, making the decision of whether to use a new agent equivocal. Complicating the decision further are the clinical and societal positions of nursing home residents. That is healthy for all of us.
Physicians have an ethical obligation to consider that residents are in special circumstances.
While, in general, the elderly are often at risk of having their autonomy compromised, residents in the nursing home are even more at risk. Balancing the principles of beneficence and nonmaleficence against autonomy and freedom in nursing home residents is an extremely delicate process, and the issues of each case must be considered individually. The above quotation succinctly summarizes the problems facing the consultant pharmacist in a managed care, nursing home environment as well. Under a legal directive to review the medications of each resident and recommend changes, the consultant pharmacist must balance the ethical obligation to assure the best possible pharmacotherapy for each resident with the realities of cost containment under capitated plans, fixed-rate reimbursement schemes, MAC caps, and TennCare limits. As the Archives article points out, one ethical precept often lost in the nursing home milieu is that of autonomy.