Get Thee Right: Lessons from Romeo's Apothecary
Were it that pharmacists need only concern themselves with the challenges posed by the clinical problems of individual patients, then our current practices would need no inspection. Alas, it is not so. Pharmacists face other challenges; challenges that question their obligations as health care professionals, obligations assigned by society and affirmed by doctrine.1 The most difficult of these challenges usually involves the economics of health care. Certain personal or organizational economic situations may cause or motivate pharmacists to invent, carry out, or acquiesce to actions that compromise ethical standards. While most pharmacists respond to these challenges appropriately, even heroically, some do not.2 
 
When pharmacists make wrong decisions under personal or organizational pressure, they often do so by compartmentalizing their professional obligations, knowingly or unknowingly. They reason that, if their decisions are not made in the context of a specific patient's clinical problem, then there is no context for professional obligations and standards. Those obligations and standards only count when these pharmacists are adorned with a white coat, name tag, and beeper.3 
 
We can lament that this is the plight of the modern-day pharmacist. We can say today's pharmacist is caught off guard by the rapid transformation of health care: that complex economics embroil them; that they are unprepared; that they can not be held accountable. But, while some particular complexities of health care may be new, the risk of compartmentalization is not. We can see that in a 400-year old text, and we can take lessons from that same text. 
 
 
In Act V, Scene 1, of Romeo and Juliet, Shakespeare not only gives an example of how long-standing the problem of compartmentalization in our profession is, but also provides a lesson on how pharmacists rationalize decisions that professionalism would never countenance.4 In this scene, Romeo, distraught over the seeming death of his beloved Juliet, seeks an apothecary who will dispense some poison that will end his life. He calls out: 
 
What, ho! apothecary! 
 
Come hither, man. I see that thou art poor: 
 
 
 
 
 
The use of the word “poor” refers to more than the lack of money. Romeo has found an apothecary who is indeed poor in finances, but also one who is poor in spirit, poor in professionalism, poor in ethical resource. Romeo intends to take advantage of this apothecary who is so poor in so many important respects. Romeo offers the apothecary 40 ducats for a dram of poison that will make him dead in no time, or as his apothecary put it: 
 
That the life-weary taker may fall dead 
 
And that the trunk may be discharged of breath 
 
As violently as hasty powder fired 
 
Doth hurry from the fatal cannon's womb. 
 
 
 
 
 
The apothecary is intrigued by the proposition, but hesitates when he recalls that there are societal constraints against selling poison or knowingly harming people in any way. Romeo goes to work. He says: 
 
Art thou so bare and full of wretchedness, 
 
And fear'st to die? famine is in thy cheeks, 
 
Need and oppression starveth in thine eyes, 
 
Contempt and beggary hangs upon thy back; 
 
 
 
 
 
In a contemporary setting, the pharmacist might hear that argument as: Isn't the boss all over you? Aren't you afraid of getting fired? Don't you want that bonus? Romeo bores in: 
 
The world is not thy friend nor the world's law; 
 
The world affords no law to make thee rich; 
 
Then be not poor, but break it, and take this. 
 
 
 
 
This “world” that Romeo speaks of could be the profession of pharmacy, and “the world's law” its professional obligations and standards. In our time, Romeo may have said: “This has nothing to do with professionalism. This is a business transaction. Professionalism will do neither you nor your business any good. You're off the hook.” 
 
 
The apothecary, having succumbed to Romeo's argument, is now able to push aside his professional obligations to make way for his business decision, and can therefore respond: 
 
My poverty, but not my will, consents. 
 
 
 
 
 
By separating his poverty from his professional obligations—that is, his will—the apothecary is able to provide Romeo with poison through a business transaction. Indeed, Romeo solidifies the separation of business objectives from professionalism by telling the apothecary: 
 
I pay thy poverty, and not thy will. 
 
 
 
 
 
After seeing how successful his efforts were to get the apothecary to compartmentalize his professional obligations, Romeo warns the apothecary about important consequences of his actions: 
 
There is thy gold, worse poison to men's souls, 
 
Doing more murders in this loathsome world, 
 
Than these poor compounds that thou mayst not sell. 
 
 
 
 
In other words, making wrong judgments about the use of a drug for a patient in the clinic is not the only way pharmacists can do harm. Pharmacists are called to make judgments in many places beyond their familiar, clinical world. Large numbers of people can be harmed at once by a single, policy-level decision that could meet some set of business objectives but not conform to pharmaceutical care concepts. Worse, large numbers of people could be harmed forever more if the fitness of pharmacy as a profession is open to question. 
 
Romeo's interaction with the apothecary is a vivid example of how the professional obligations of the pharmacist can be vulnerable in certain circumstances. This scene dramatizes an important reality; ethical reasoning can be severely compromised and eventually lost. Shakespeare reminds us that the roles pharmacists play are not always located in the clinic, and that as graduates of professional schools and licensed practitioners in society, pharmacists always carry the obligations of a health care professional. He also tells us that what we face in the way of these challenges is not a problem of just our time; that we have and always have had a duty to comply with our standards in the face of complexity, change, and pressure. 
 
How appropriate that Shakespeare embeds this lesson within a tragedy. A failure of professionalism of the nature described in Romeo and Juliet is tragic. It is tragic to the people whose trust is violated, it is tragic to pharmacy's stake as a helping profession, and it is tragic to the soul of the pharmacists involved. Pharmacy education and training focus mostly on clinical concepts, for good reason. The focus is thus on the body, but it is in the soul where professional obligations reside. Shakespeare is telling us that we must look to our soul to keep our obligations whole, and that if we fail in this, then we, ourselves, become “worse poison to men's souls.” He is telling us, each of us, get thee right.