Doctor Knows Best? The Ethics of Self-Prescription
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for Bioethics
University of Minnesota
The most recent issue of JAMA reports the results of a study of self-prescription among residents in four leading internal medicine residency programs. There is ample evidence that practicing physicians commonly self-prescribe, but until now, little has been known about the practice among residents. Because residents work unforgiving and long hours, it is understandable that they would find it difficult to seek medical care for themselves. But it is just because of their status as physicians in training and their stressful workload that we ought to consider the wisdom of self-prescribing.
The combination of workload and convenience of drugs make it easy to see that residents have both access and motivation to self-prescribe. But access and motivation are an invitation to irresponsible use of medications, with little or no oversight. As the authors of the JAMA article suggest, our goal ought to be to " . . . ensure that convenience and easy access do not undermine professionalism in the prescription and use of medications." What are the factors that might threaten professionalism?Judgment clouded by illness
On one hand, self-prescription offers the best possible combination of informed physician and informed patient -- but unfortunately in the same person. Clinical judgment can be clouded by the very reason the physician seeks prescription drugs. As anyone who has suffered from illness knows, even the common cold or flu affects the way we feel and can negatively affect our judgment.
Physicians understand this issue in their own patients and the problems it creates for appropriate informed consent, and that is part of the reason they work hard to encourage good decision-making that may include family members and others. Physicians have the advantage of knowledge that is so important to medical decision making, but knowledge clouded by illness could lead to inappropriate and even dangerous self-treatment.
Care for others, care for yourself?
When a physician is also a patient, who oversees the prescribing behavior? Access to certain drugs only by prescription offers an important safeguard to assure their appropriate use. Residents have their medical decisions reviewed, and in some respect overseen, by more experienced attending physicians to further assure patient safety. When residents self-prescribe, there is no such oversight.
Further, we generally don't think it's appropriate for physicians to treat members of their own family, for good reason-they cannot be sufficiently objective. The same argument applies to self-prescribing, and is even magnified since the physician is treating him- or herself.
Can good professional judgment include self-prescription?
Of course not all self-prescribing includes drugs that might be dangerous, for instance beta-blockers for stage fright or antibiotics for a suspected ear infection. But self-prescribing that delays proper diagnosis and treatment of illness, or that involves taking inappropriate drugs or dosages raises serious ethical and safety concerns. Residents should be encouraged to seek appropriate health care, when feasible, and at least to discuss health issues with their colleagues to obtain some objective feedback.
No man (or woman) is an island, in spite of how residents are often expected to perform. Issues of self-prescription ought to be discussed in residency programs and its more dangerous aspects discouraged. Learning good professional judgment is part of residency training, and it is important to ask whether self-prescription and professional judgment can coexist.
"Ethics Matters" Archive
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on a wide range of bioethics topics.
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