What if patient requests an advertised medication?
What if patient requests an advertised medication?
Patient's values are central
If a patient comes to a provider asking for a specific name-brand medication, how much weight should the request be given?
"There is a big difference between a patient saying, 'I need something' and "I need this medicine,'" says G. Caleb Alexander MD, MS, affiliate faculty of the MacLean Center for Clinical Medical Ethics and an assistant professor in the Department of Medicine at the University of Chicago. "My radar would be higher if the patient came in insisting that a single medicine was the right one, because that's rarely the case."
This type of request presents an opportunity for the provider to clarify misconceptions the patient may have about the medication, adds Alexander, and to explore other options such as lifestyle modifications or over-the-counter therapies.
Prescribers may face an ethical conflict between respecting the patient's wishes for a specific therapy and their obligation to act as an agent on the patient's behalf, he says.
"The concern is when the patient is requesting something that isn't clinically indicated," Alexander says. "Normal and pathological conditions aren't always crystal clear. There are gray areas in medicine, and physicians can be unduly influenced in ways they are not aware of."
Balancing risks, benefits
The physician is not an expert on the patient's values, and "within the constraints of the law and conscience, these values necessarily should control the pharmaceuticals the patient consumes," according to Robert M. Veatch, PhD, professor of medical ethics at the Kennedy Institute of Ethics and a professor in the Philosophy Department at Georgetown University in Washington, DC.
"It cannot be the physician's responsibility to control what the patient consumes," he says. "Physicians retain the right to refuse to prescribe drugs requested by patients, and they usually should refuse when the drug is useless."
The physician's job is to educate the patient about the effects and then decide whether to prescribe the medication, he adds. "Balancing risks and benefits is a very complex process," he says. "The patient has an absolute right to refuse the physician's value judgments about which medications to consume."
While the physician retains the right to refuse to prescribe, normally he or she should not refuse based on the physician's beliefs and values when these differ from the patient's, Veatch argues.
"'Shared decision making' is a strange concept. No doubt it is more in fashion today, but we need to understand a proper sense of sharing," says Veatch. "If by 'shared decision making,' one envisions a situation in which physician and patient get equal vote or where there must be complete agreement, that is a bad version of sharing."
Instead, Veatch advocates for a "division of labor" approach. "The physician is surely the expert on the medical facts of diagnosis, prognosis, and pharmacology," he says. "He or she should be presumed authoritative on these matters of fact."
Sources
- G. Caleb Alexander MD, MS, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD. Phone: (410) 955-8168. Email: [email protected].
- Robert M. Veatch, PhD, Professor of Medical Ethics, Kennedy Institute of Ethics, Georgetown University, Washington, DC. Phone: (202) 687-8099. Email: [email protected].
Drug ads: "Ethical scrutiny" continues Direct-to-consumer advertising of prescription medicines "remains an important area of ethical scrutiny," says G. Caleb Alexander, MD, MS, associate professor of epidemiology and medicine at Johns Hopkins University and former affiliate faculty of the MacLean Center for Clinical Medical Ethics at the University of Chicago. "I don't think health care would suffer appreciably if direct-to-consumer advertising were to be banned. We are the only country in the world that allows it," Alexander says. While advertisements viewed by consumers may help destigmatize conditions such as depression, he says, these clearly contribute to the overuse and unnecessary use of prescription medicines. Direct-to-consumer ads are associated with increased prescription of advertised products, with a substantial impact on patients' request for specific drugs, according to one review.1 A 2012 review linked the advertisements to less appropriate prescribing and switches to less cost-effective treatment.2 A 2003 study suggests that more advertising leads to more requests for advertised medicines, and more prescriptions.3 Although there are several thousand drugs available on the market, the top 25 advertised drugs accounted for two-thirds of all spending on direct-to-consumer advertisements, according to Alexander. "People see the ads all the time and may think there are hundreds of drugs being advertised, but that is not the case," he says. Advertisements tend to feature drugs with broader clinical indications for their use, such as therapies that can be used for multiple conditions or by a broad population, he notes. "Based on most of the evidence about direct-to-consumer advertising, it's safe to say that patient requests can be influential in shaping treatment choices," Alexander says. "The ethical challenge for providers is ensuring that they are not unduly influential." References
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If a patient comes to a provider asking for a specific name-brand medication, how much weight should the request be given?
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