The ethics of off-label use of drugs: oncology pharmacy in Italy

The off-label use of drugs is very common in cancer treatment for many reasons. This practice is challenging for pharmacists who practice in oncology, for bureaucratic and medico-legal reasons and for reasons concerning ethics. Several Italian legislative Acts and Laws allow pharmacists to have a voice in the management of off-label use of drugs in oncology and offer instruments to allow reasoning from an ethical perspective. The main aim of this paper was to identify the role of pharmacists within the ethical context in the off-label use of drugs in oncology, taking into account the legislative framework and clinical oncology setting. We consider the existing norms to develop an ethical perspective, through the values underlying the Laws and Acts. From a hermeneutical perspective, we focus on the actual oncology setting to identify the ethical space. The off-label use of drugs in Italy is currently regulated by Law 648/96, Law 94/98 and Decree Law on the therapeutic use of drugs under clinical investigation. From the oncology pharmacist's perspective, the application of the Laws mentioned is often problematic. The disease itself brings forth many ethical issues. In particular, human experience is extremely important in oncology and cannot be separated from other considerations. When faced with the common choice of oncologists to use drugs off-label the late stages of the disease or after many chemotherapy attempts, pharmacists have to take responsibility for the sick person. This usually involves collaboration with the physician, within a process oriented by the 'circumstances of compromise in ethics'. The pharmacist practising in oncology should promote real collaboration especially with the physician for the benefit of the sick person. The pharmacist has to maintain his/her professional integrity, and orient it towards accurate evaluation of the so-called 'circumstances of compromise in ethics'.