The Quality of Mercy

"I imagine that the first question the priest and Levite asked was: 'If I stop to help this man, what will happen to me?' But by the very nature of his concern, the good Samaritan reversed the question: 'If I do not stop to help this man, what will happen to him?” Martin Luther King Jr., Strength to Love

"If you haven't got any charity in your heart, you have the worst kind of heart trouble." Bob Hope

Several months ago I picked up a book on a lark at the local library called, “Giving: How Each of Us Can Change the World,” by President Bill Clinton. The book is a collection of vignettes that describe how ordinary people of all ages and stripes have undertaken missions of charity, and accomplished extraordinary things. The good deeds described range in scale from small and common, to grandiose and complex; from matters of pennies, to matters of billions of dollars. The point of offering such disparate examples is: that no act of charity can fairly be judged too small, and that mercy is infinitely available in sizes to fit all. I came away from that short read determined to do my own good, for goodness sake. The scales fell from my eyes.

I once read that five to eight percent of the deaths of individuals aged sixty five years and older in this country are related to influenza and influenza associated pneumonia. I am a certified immunizer. Influenza and pneumonia immunizations are completely covered by Medicare and Medicaid. People sixty five years of age and older are all enrolled in Medicare. Thousands of people sixty five years of age and older are confined to their homes in my home county, Monroe County, Michigan. Do you see where I am headed here? I decided to form a charity called “Sociably Secure-NGO” with the mission of immunizing all home-bound seniors in my county against influenza and pneumonia. A pharmacy connection seemed natural.

I networked with the directors of more than a dozen county charities devoted to providing similar services to seniors, to seek guidance and direction. I will continue to use this network to generate referrals from my new colleagues, identifying seniors in need of help. I learned how to form a non-profit organization. I am actively compiling a contacts database of seniors in my county who are physically, socially, and economically home-bound. I have named it “The Monroe County Silver Pages.” A brilliant friend of mine and I are writing a web-based application that will allow other charity directors to legally access this contacts database on a restricted, subscription basis; so that we can all freely contribute to the list, grow the information organically, and share in the fruits of our common labors. I got out of the gate too late to have all ducks in a row for this year, but will work doubly hard to assure that the job gets done each year going forward.

One of the other charities that I encountered in my research is “The Monroe County Opportunity Program, MCOP.” This program centers around a fully functional grocery store, staffed by a volunteer labor force that issues its own currency to eligible county residents on the basis of economic need. It serves the shopping needs of the county’s working poor, with aisles stuffed with groceries and cereals, coolers of frozen food, racks of produce, and shelves of baked goods. The charity does a great job of soliciting enough foodstuffs, but has a more difficult time keeping its shelves stocked with toiletries like: bar soap, mouthwash, toothpaste, toothbrushes, shampoo, shaving cream, razors, and deodorant. I volunteer to utilize my pharmacist connections to keep the “medicine cabinet section” of the store well stocked. I appended this task to the mission of my own organization. Yet another natural pharmacy connection.

I hope I am not being too gooey here, and I am not trying to thump my own drum. I intend only to underscore Mr. Clinton’s thesis that for fellow pharmacists, the quality of mercy is not strained.

“The quality of mercy is not strained; it droppeth as the gentle rain from heaven upon the place beneath. It is twice blest; It blesseth him that gives and him that takes."

 The Merchant of Venice, Act IV, Scene I, William Shakespeare,1564- 1616

To wit: mercy and charity cannot be demanded or forced, but must rather be offered freely to function well.

We all have abundant good works in our hearts. We simply often lack self-confidence that our actions will be good enough, grand enough, to be deemed worthy by those who daily judge us. This need to measure up is consistent with our human nature. Seek strength and confidence instead from the inherent quality of mercy, and know that any charitable action you offer stands on strong legs. Then, judge yourself.

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Earth Angel

“Angels of highest light and love,
Angels that radiate beams of pure energy from the heavens above.
Please join us and be with us on this very night,
As the soul of our beloved joins you in flight.
We pray that you send this soul embraced in your lovely wings,
During his journey may he hear harps, and trumpets and strings.”
Molly Friedenfeld, The Book of Simple Human Truths

“No, I never saw an angel, but it is irrelevant whether I saw one or not. 

I feel their presence around me.”
Paulo Coelho

My first recognizable time occurred traveling downward in an elevator at the huge inpatient facility of the Cleveland Clinic in Ohio. Thankfully, that time was not my last.

My mother-in-law, Doris, had asked me to escort her to an appointment for a medical examination with a heart specialist in Ohio, and I agreed. She, my wife, and I sat stuffed chock-a-block in a warm cattle-car holding room patiently waiting our turn.

A pretty young woman with her scalp shaved bald and marked by angry, red, fresh surgical scars suddenly tore a gaily printed green silk scarf from around her neck and wailed in full-throated terror; “no you can’t, no you can’t, no you can’t!” She then abruptly calmed, meekly looked around the room like she was seeing us all for the first time, and then lowered her face to weep embarrassed tears. No-one held her.

A few minutes later Doris gripped my arm, said, “oh, my,” and slipped bonelessly from her chair to the floor. Our visit dissolved into a whirling world of grabbing hands, white uniforms, and hurried gabbling voices.

When next we saw my wife’s mother, an eternity later, she was strapped into a hospital bed; festooned with wires and tubing, and cocooned in warbling machinery. Holes were cut in her swollen head and in her throat. Bright red stained the whites of both eyes. A respirator rhythmically inflated-then-deflated her. The world buzzed loudly in our ears. A doctor and two white jacketed hangers-on took me aside and blandly counseled me to prepare my darling wife for the very worst of news.

We silently rode an elevator downward, shared with a quite elderly negro woman dressed in the blues of a hospital housekeeper. My wife started to silently weep right after the doors slid closed, then her body heaved with the force of great loud sobs. The housekeeper took her by her shoulders, turned her, tenderly enveloped her… then cooed, “oh come here now, baby… there, there, there.” She petted my wife’s hair, she whispered sweet comforts in her ear. Grateful tears tracked down my cheeks. I briefly and guiltily thought of the frightened, bald young girl in the pretty green printed scarf.

We took Doris back to our home to die. She had likely died peacefully right there in Cleveland; but she officially died in a hissing and mechanical sleep in Michigan just a few short months later.

I have since seen that elderly housekeeper a few more times now over these many decades. She schooled me to watch for her. Of course, it was not actually her… but it was her; offering unselfish sweet succor; as patients, and friends, and family, and loved ones lay dying.

She shone from the eyes of a hospice nurse who tended my dying father; as she comforted, and smiled, and joked, and made his way easier. She radiated from the breaking heart of my older brother just a few short months after father died; as my brother held my dying mother in his arms, stroked her hair, and whispered magical sweet comforts in her ear.

Abraham Lincoln once exhorted all listeners to trust in their faith and inner strength with this famous counsel: “when again touched, as surely they will be, by the better angels of our nature.” Were those angels there for him at his time of greatest need?

I don’t know if there are better angels, but I hope so. I pray that they have been with us unseen all along. I may have just recognized one for the first time, traveling downward in an elevator… at the Cleveland Clinic, in Ohio.

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Tied to the Whippin’ Post

“Sometimes I feel, sometimes I feel,
Like I been tied to the whippin' post.
Tied to the whippin' post, tied to the whippin' post.
Good Lord, I feel like I'm dyin'.”
Allman Brothers Band

“... you don't have to wait for someone to treat you bad repeatedly. All it takes is once, and if they get away with it that once, if they know they can treat you like that, then it sets the pattern for the future.”
Jane Green, Bookends

A worn and dusty edition of “Remington’s Pharmaceutical Sciences” from the nineteen- fifties, turned up in the basement of a pharmacy I bought twenty long years ago. It still holds a treasured place in my professional library. A section covering the theory of professional pharmacy practice offers up some advice and some caveats that ring oddly sound when applied to current day circumstances.

A paraphrased thumbnail sketch of this ancient pharmacy wisdom reads as follows:

• A pharmacy professional’s primary focus and responsibility is the well being of the patient. Concerns about job security and about compensation should never be allowed to interfere with the primary duty to the patient.

• Professional compensation and job security must be closely monitored and adjusted to be kept sufficient enough to prevent these concerns from becoming issues that cloud judgment and interfere with a pharmacist’s duty to the patient.

• External commercial business concerns must be kept strictly segregated from everyday professional pharmacy practice to prevent them from interfering with the duty to the patient. The well being of the patient reigns supreme over the profit motive of the business side of the pharmacy practice.

It is tempting to dismiss these suggestions as quaint and antiquated bromides from the yellowing pages of a bygone era in professional pharmacy practice. That would be hasty. These guidelines might carry more import now than they did seventy years ago. In a nod to outspoken sports commentator, Charles Barkley, “I might be wrong, but I doubt it.”

The job market has gotten pretty tight for pharmacists recently. There are fewer independently owned pharmacies providing practice opportunities, due to a hostile and restrictive insurance billing environment. Tight reimbursement conditions for hospitals are driving cautious hiring practices and personnel reductions. There are way too many licensed pharmacists due to excessive graduation rates from a burgeoning number of schools of pharmacy. Fewer round holes… too many round pegs.

When job postings become rarer than the teeth in chickens, job openings become dearer commodities. A power advantage swings toward the employers who control the jobs. The possibility that the needs of these employers might be placed ahead of the needs of patients becomes an increasingly clear and present danger. Things only amplify when the job market looks so glum, that pharmacists are petrified by the prospect of losing a job for fear of not being able to find a suitable replacement. A job can become a precious facet of life; one not to be surrendered at any cost, or under any circumstances.

If the power balance between employers and pharmacists becomes sufficiently distorted; employers may dub themselves as proxy manipulators of the professional activities and the practice judgment of the pharmacists employed. My way or the highway! Pharmacists, who resist employer interference in professional conduct, may do so at very real risk of punishment. The threat of termination makes for a pretty effective lash. Feet to the fire! The primacy of patient welfare and safety often gets lost in the mix.

It is unlikely that most pharmacist employers are meddlers and workplace bullies; but neither is it a good idea to allow them that option. Discussions with other pharmacists and with persons working at the various professional associations might be a good way to keep tabs on the scope and the extent of the problem. Social websites offer another great forum for sharing state-of- the-profession discussions like this one.

Worsening of practice conditions can be a direct cause for professionally disenfranchised pharmacists to become too timid and too unwilling to just-say-no. The end result can be: crushing prescription dispensing burdens, reduced levels of technical support staffing, slipshod immunization efforts, ineffectual Medication Therapy Management programs, shrinking compensation, and worse.


A recent and widely publicized crackdown on the irresponsible dispensing of abuse-able controlled substances by several large pharmacy companies; provides just one cautionary example of pharmacists displaying poor practice judgment while under the gun; perhaps at the behest of their bullying and meddling employers. All this, in a social climate where demise by prescription narcotics has become a leading cause of death in the country. What was the thinking here?

All things considered, however, the threat of punishment by an employer does not excuse a pharmacist for failing to: exercise good professional judgment, exhibit ethical behavior, and perform the job in a fashion that is always in the best interests of patients. Strong personal reasons… do not good excuses make. The decision to practice under unsafe conditions, to knowingly contribute to high prescription error rates, to dispense narcotics unwisely, to rubber-stamp-and-phone-in important clinical services… those things are completely on us. We are the sworn professionals.

The notion that job mobility might be an effective shield against outside meddling with professional practice and conduct… seems sensible. The concept is worthy of mention in any era’s “theory of professional pharmacy practice.” Maintaining a healthy balance in the pharmacist labor force can be viewed from this perspective as an aliquot of responsible stewardship toward the profession, by its members. Pharmacists should be willing to work with one another and in concert with their professional associations to promote workforce mobility… as if the very well being of their patients depended upon it. Patient morbidity and mortality do indeed come into play.

Pharmacists are bound by honor and by ethics to closely guard the best interests of the patients whom they serve… above all else; our own selfish interests or the selfish interests of those who employ us notwithstanding. Promoting employment mobility to bolster professional autonomy may seem like a yellowed, dusty, and old fashioned suggestion… but it may instead be a timeless strategy. The yardstick against which we measure present pharmacist performance might be calibrated by observing how well we utilize effective practice principles like this one from the past… even while tied to the whippin’ post.

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Support efforts to fund and bolster the pharmacists’ Aggregate Demand Index (ADI). Be good stewards of the pharmacy profession you so dearly love. Visit pharmacymanpower.com