We studied variability of answers across the three age categories: [23-40], [40-55], [55-73].

Highly significant difference (p≤0.001) was shown between the three age categories when asked about considering continuous education (CE) as optional but recommended: the highest level of disagreement in considering the CE optional but recommended was in the youngest category showing 25% disagreement with this statement and this disagreement decreased with age, While 65% of the younger category of age had the highest total agreement that CE was essential for maintaining licensure showing concordance between these two answers (Figure 5).

When considering always referring to a physician’s opinion and if they follow hospital policies without exception, the difference between age categories was highly significant (p<0.001): answers showed 61% of the smallest age category not agreeing always referring to a physicians’ opinion.

Significant differences were also found in considering the CE essential not only for personal knowledge but for maintaining licensure as well and the idea that technology extends the reach of pharmacists beyond the traditional community pharmacist setting and in encouraging patients to stockpile unused drugs for potential future use. Among the pharmacists aged between 23 and 40 years 34% would encourage patient to stockpile drugs for potential future use and there was statistically significant difference between age categories. Also, there was a significant difference among age categories when asked about following the hospital policies without exception, the age category between 40 and 55 having the highest disagreement of 65%.

Results of the bivariate analysis for the association between age and ethical behavior and practice are summarized in Table 2.

Significant divergence was shown between pharmacists working in Beirut and Mount Lebanon and the pharmacists working in the other regions when pharmacists were asked about continuous education: pharmacist working outside Beirut and Mount Lebanon were more in favor of considering it optional but recommended and the difference was significant (60% vs 57%, p=0.041) while 64% of those living in Beirut and Mount Lebanon did not agree of limiting this requirement to academic pharmacists vs 59% of those living in the other regions and this difference was significant (p=0.032). Overlooking expiry dates to minimize wastage was also significantly divergent between pharmacists working inside Beirut and Mount Lebanon and those working in the other regions: those working outside Beirut and Mount Lebanon refuse overlooking expiry dates in 77% of cases compared to 67% in the other group (p=0.017) (Figure 6).

Some ethical considerations were significantly different between those who work in a community pharmacy and all other working fields: hospital and clinical pharmacists, industry related pharmacists, marketing and companies’ regulatory affairs, academicians as well as students. Results showed significant association between working field and promoting self-medication education: those working in community pharmacies are significantly more prone to promote self -medication (p=0.05) and are more in favor of considering continuous education as optional (63% vs 56%, p=0.05). Highly significant association was found between selling patients unneeded products to achieve higher target sales and the fact of being or not a community pharmacist (34% of community pharmacist accept to sell unneeded products vs 26% of participants working in the other fields, p=0.002) (Figure 7). Moreover, community pharmacists showed more implication in focusing on personal development compared to other fields (39% vs 30%, p=0.002).

Results of the bivariate analysis for the association between working region as well as working field and ethical behavior and beliefs are summarized in Table 3.

Based on a scoping review on pharmacy practice and clinical pharmacy research in the Middle East 19 and to our knowledge, this is the first observational prospective cross-sectional study in the middle east region targeting all pharmaceutical sectors and aiming to explore ethical behavior and believes of pharmacists and pharmacy students in three directions: pharmacist and patient, pharmacist and his colleagues and pharmacist with medical and regulatory authorities providing a comprehensive analysis of pharmacists' knowledge and attitudes towards ethics and good pharmacy practice.

Pharmacists showed consistency and adherence to ethical behavior and patient care in terms of confidentiality and quality of service (more than 90%), the relation pharmacist-pharmacist as well (more than 90%) and sustainability by promoting eco-friendly solutions (90%) while partially showing interest in digitalization (76%) in their daily practice. Financial pressure may impact the ethical behavior of some pharmacists who are willing to compete by selling unneeded products to the patients (68%) allowing financial incentives to impact their professional advice (14%) and encouraging stockpiling and competing by selling medicine below official price (12%) while considering drug delivery not violating the law of fair competition among pharmacists (11%). Pharmacists showed high concern for patient confidentiality (61%) and were engaged in continuous education considering it essential for maintaining licensure (80%).

When answering case studies, participants showed adherence to guidelines and regular authorities: the highest category (50%) believed in preventing potential harm and 26% would address regulatory authorities in case of suspicious clients. Moreover, the study shows the more pharmacists increase in age the more they give importance to continuous education. The category of pharmacists between 23 and 44 years was the most to encourage stockpiling medicine while those working in Beirut and Mount Lebanon were less prone to encourage overlooking medicine expiry dates compared to other regions.

The study shows community pharmacists are more prone to encourage self-medication highlighting the trend towards increased self-medication and self-care 20 and selling unneeded products while they are more implicated in self-development compared to other working fields.

Our findings shed the light on the pivoting role of the Lebanese pharmacists in the health care system and this contrasts with the situation in Pakistan where the health care system has yet to recognize the pharmacist's role, and this lack of recognition is due to the limited interaction of pharmacists with the public 21.

Participants had different approaches when dealing with ethical dilemmas without dominant answer aligning with a study by Hibbert et al.,2011 in the United Kingdome showing that community pharmacists may respond to the same ethical dilemma in a different way. This situation is acceptable since ethical dilemmas often have more than one right answer 22: there have been few international studies of the moral dilemmas experienced by community pharmacists, and existing studies vary widely in aim, method and presentation of results 10. In Netherlands a study exploring ethical dilemmas confronting community pharmacists showed the relationship between the pharmacist, patient and other health professionals was complicated by other parties, such as legal representatives, health insurance companies, and regulators 10. Most of the challenges of pharmacy practice are related to professionalism and professional commitment 23 and ethical guidelines mainly target community pharmacists 24. Research by Blenkinsopp et al., 1996 20 shows that community pharmacy is not profit motive predominated; a study on Swedish community pharmacists show that today's pharmacy is not focused on improving the use of medication, possibly resulting in the patient not gaining the most benefit from his or her treatment 25. Also, an Australian survey on community pharmacist and interns showed interns reported more exposure to potential practice privacy breaches 26.

In pharmacy practice four ethical principles are measured and judged in interaction with one another: autonomy and beneficence of the patient, the principle of non-maleficence and finally the principle of justice 27.

Our study shows financial pressure affects ethical behavior and impacts pharmacists’ professionalism, and this is also shown in studies done in other countries: according to Salari et al., 2013 pharmacy students as well pharmacists in Iran are under the pressure of accepting a gift from pharmaceutical companies by their own. and confirmed the necessity of teaching the principles of professionalism in addition to providing an ethical guideline 7.

In Saudi Arabia, a study by Al Arifi et al. showed that only 43% of the community pharmacists would sell medication over the counter to a patient who does not really need it 2 whereas in our study selling unneeded products to the patients was accepted by 68% of participants: both studies showed that pharmacists are struggling in their daily practice and the community pharmacists are under commercial pressure and more concerned about their own financial interests.

Our findings highlight the pharmacists’ professionalism in handling prescriptions by discussing with healthcare providers (93%) and referring to regulatory authorities (61%) and these findings align with the results of a cross-sectional study in Jordan on community pharmacists showing pharmacists tend to discuss and share decisions with their peers and healthcare professionals 1. This is in contrast with what is found in a study by Rajiah et al., 2018 in India showing community pharmacists are in extreme dilemma when handling a prescription from a physician though the medication prescribed is inadequate in therapeutic effect 12.

In terms of pharmacists’ discretion and respect to patient’s confidentiality our results aligned with those observed in Malta: 91% of consumers were satisfied from pharmacist discretion 28. Patient confidentiality is a concern in rural pharmacists experiencing unique ethical dilemmas in relation to practice isolation, privacy and confidentiality 9. Moreover, most of participants prioritized patient welfare (90%) and this finding aligned with the results of other research done by Benson et al when pharmacists ranked ‘patient welfare’ as the most important indicator of the quality of practice 8. More recent research in Australia has also identified patient welfare as the core ethos underlying pharmacy practice 29.

There are often complex health-care system pressures in the hospital setting that cause pharmacists to behave in ways that may conflict with professional values and behaviors 24. A wide range of contemporary ethical issues unique to hospital pharmacy practice, mostly involving complex medication management safety, supply, and cost scenarios, were identified explaining the need for additional training, mentorship, and availability of hospital-specific targeted ethics resources 30 therefore in Australia, hospital pharmacists rely on discussions with colleagues to brainstorm how to address ethical issues 24.

This cross-sectional study revealed Lebanese pharmacists have a strong commitment to ethical standards particularly in promoting patient’s wellbeing with collaboration and transparency seen as crucial elements of their role.

Divergence is revealed in areas concerning profit-driven practices, promoting self-medication, and certain advertising standards shedding the light on real-world pressures such as financial incentives and market competition that may challenge these ideals in practice. Continuous education on ethics, technology integration, and sustainability can help further strengthen ethical practices in pharmacy. Additionally, clearer guidelines on handling ethical dilemmas would help standardize responses across the profession.

Further research on a large scale is needed in this area of practice to improve the code of ethics and to guide Lebanese pharmacists in their daily practice.