Medical Ethics and the pandemic flu

[skepticdoc]

This was posted in a Physician only list serve:

You are a family physician in practice and an established and trusted
patient presents to your office with a request for a prescription for
Tamiflu, so that he could keep it on hand in case there is an outbreak
of pandemic influenza. He wants to purchase the Tamiflu with his own
money and will not claim the cost of the prescription on any medical
insurance. He will only take this medicine with your OK, and just wants
to keep it on hand just in case there is none available in the event of
a pandemic. There is currently no significant incidence of influenza
and no shortage of Tamiflu. Would you write him the prescription for
Tamiflu? Why or why not?

What is your response?

 

[TriangleMan]

What is my response, why go to Wikipedia of course!

In the New England Journal of Medicine, Moscona (2005) argues that the use of personal stockpiles of oseltamivir could result in the administration of low dosages, allowing for the development of drug-resistant virus strains. Many stockpilers will only have ten 75 mg pills (the current recommended dosage for oseltamivir), but this may be insufficient for the treatment of H5N1. (de Jong et al., 2005)

Another argument against individual stockpiling is that limited drugs should be kept for more strategic or ethical deployment, that is, to hard-hit areas, to people in critical roles (e.g., healthcare and government workers), to people vulnerable to seasonal flu, or to people who actually have come down with avian influenza.

Sound like stockpiling might be bad.

Ahhhh Wiki, is there anything you don't have in (non-peer reviewed) abundance?

 

[Slimething]

I imagine it was posted in a physician's only listserve because the question only pertains to real physicians. So what's your point in asking us?

 

[JoeTheJuggler]

Isn't there a shelf-life issue as well?

 

[Dymanic]

This is actually part of a broader question -- or maybe it's an entire class of questions. The built-in assumption: "There is currently no significant incidence of influenza and no shortage of Tamiflu" makes things a little easier to address, since it limits the issue to concerns about resistance -- though that is no simple matter by itself. If you're interested in antiviral resistance in particular, I'd recommend a bit of reading:

http://scienceblogs.com/effectmeasure/2007/03/modeling_antiviral_resistance_1.php#more

If you're more interested in the broader question, I'd say it has to do with the physician's responsibility to a single patient versus his responsiblility to... unknown numbers of patients; hundreds; maybe thousands. In the teeth of a pandemic, caregivers will face tough choices, just as they often do in any emergency. Think of battlefield triage; the price of time spent treating a hopeless patient may be the life of one who might have been saved. If the goal is to save as many as possible, this must be kept in mind when allocating any resource.

Here, (given the framing of the question) that resource, as I see it, is susceptibility of the virus to the drug. Ideally, this resource would be conserved in such a way as to give the greatest possible number of people a chance of being effectively treated. Doing that may mean asking difficult questions like: which patients are at greatest risk? and: Which stand to benefit most? and maybe: Which ones are at greatest risk of passing the virus on to others? and, perhaps most difficult of all: Which ones are the most indispensible due to the importance of their roles in society?

If this were the planet Vulcan, we could maybe use our superior logic to neatly quantify all of that and act accordingly (though if you read through the lengthy series of posts that start with the above link, you'll see that even if a strategy for antiviral deployment could be consistently implemented -- enforced, I guess it really is -- there isn't any single obvious strategy that just jumps right out at you). Here on Earth, the identifiable needs of the patient right in front of you -- the one with a face, and a name -- are likely to carry more weight than vague concerns about the needs of an unknown number of patients you've never met.

Isn't there a shelf-life issue as well?

Antiviral drugs have a pretty decent shelf life compared to most pharmaceuticals. Roche has it at 36 months for Tamiflu, and it's probably better than that if kept properly. With the other class of antivirals, Amantadine/Rimantadine, it's even better. I've seen it quoted as better than five years.

 

[skepticdoc]

I imagine it was posted in a physician's only listserve because the question only pertains to real physicians. So what's your point in asking us?

This is more of an ethics/philosophy issue, I posted initially in the Religion section, some moderator moved it!

Do you have an opinion?

 

[Slimething]

Do you have an opinion?

No opinion, sorry. I don't have the expertise. Perhaps if you explain your purpose in asking the question, you would get more informed people than me replying.

 

[Dymanic]

No opinion, sorry. I don't have the expertise.

Is there any of us who can claim "expertise" concerning what is right and what is wrong?

"And what is good, Phaedrus, And what is not good -- Need we ask anyone to tell us these things?"

 

[Slimething]

Dynamic, I could offer an opinion if I knew the facts surrounding the question. You are not the OP so I can't really say that the foundation you've described is what the OP had in mind. Thus, I've asked the OP to expand informatively on his question.

So, what was Phaedrus' answer?

 

[Wat Tyler]

As a Brit, living in a country with a state-funded healthcare system, my first response is the facile 'NHS GP's can NOT sell-on medicines anyway '

But, with my non-facetious hat on:

As others have intimated, there are two problems with selling the 'gear' to the patient:

1) this action may well expedite the evolution of drug-resistant strains of the virus, and as such probably contravenes the Hippocratic Oath that Doctors swear;

2) what if the medication proves ineffective against the particular strain that causes the pandemic anyway?

Of course, with my Evil hat on:
I box a bunch of aspirin up as Tamiflu, sell him (and everyone else who asks) that, and then retire to my private island to sit out the pandemic - bwahahahahahahahahah!

 

[skepticdoc]

In the U.S. most Physicians do not sell medications.

Federal law requires a prescription to buy the medication from a drugstore.

 

[Wat Tyler]

In the U.S. most Physicians do not sell medications.

Federal law requires a prescription to buy the medication from a drugstore.

Cheers.

To clarify (because I forgot to include this bit in my last post. D'oh!), were I a Doctor, I would refuse to sell him the prescription, for the reasons that I put in my last post - it might not work anyway (so I'd be ripping-off a trusted patient), and doling it out may, in fact, precipitate a more-serious pandemic later on.


What is/are your answers to the question?

If you are on a Physicians-only list, I presume that you are one, and have taken the Hippocratic Oath.

Does the Oath affect your answer to the question?

 

[Gurdur]

...were I a Doctor, I would refuse to sell him the prescription

To point out this again and more generally:

Physicians commonly do not sell prescriptions.

So if you post again on this, please change it to, "I would refuse to write him a prescription" or "I would refuse to prescribe it".

If you are on a Physicians-only list, I presume that you are one, and have taken the Hippocratic Oath.
Does the Oath affect your answer to the question?

Most or many USA physicians do not take the classical Hippocratic Oath. UK docs do not take it at all. In general, the Hippocratic Oath has been succeeded in many places by the Declaration Of Geneva.

Here is the UK GMC Duties Of A Doctor, and also the GMC Good Medical Practice guidelines.

Just as well, or any doc operating on you for kidney stones would be contravening the classical oath.

 

[Wat Tyler]

To point out this again and more generally:

Physicians commonly do not sell prescriptions.

So if you post again on this, please change it to, "I would refuse to write him a prescription" or "I would refuse to prescribe it".

Ah, OK.

Would you write the requested prescription?

Most or many USA physicians do not take the classical Hippocratic Oath. UK docs do not take it at all. In general, the Hippocratic Oath has been succeeded in many places by the Declaration Of Geneva.

Here is the UK GMC Duties Of A Doctor, and also the GMC Good Medical Practice guidelines.

Just as well, or any doc operating on you for kidney stones would be contravening the classical oath.

OK, then I'll rephrase my previous question:

Would writing the requested prescription contravene any terms of any of the documents you mentioned?

(I'd guess that it wouldn't directly contravene any, otherwise skeptidoc's original question would never arise.
But I'd still be interested in getting the opinion of a qualified person.)

 

[Gurdur]

Ah, OK.
Would you write the requested prescription?

Sometimes yes, sometimes no. I'm answering generally.

This question is far more tricky than is thought. What is the patient is depressive and in an anxiety state? Tons more interesting ways the situation can be made more complex. Normally, I personally would try hard arguing any such patient out of such a thing.

Caveat: although I was involved in one of the ancillary medical sides of life, diagnosis, treatment, and rehab of aphasiacs, apraxics and some other neuro disorders, I personally do not have the authority to issue prescriptions, so you might like to discard my opinion.

Would writing the requested prescription contravene any terms of any of the documents you mentioned?

Depends who you talk to. Really. This is a nasty complex area. And you will find quite a large cultural medical difference between the USA and the UK on this.

To make your question sharper, you could ask:
Could a physician be disciplined by a medical council in the UK for committing such an act?

I believe perhaps; it really would depend on the mood everyone was in at the time. One of those issues that can fall either way depending on politics of the day, mood and interpretation of the guidelines.

 

[Wat Tyler]

Depends who you talk to. Really. This is a nasty complex area.

I've occasionally encountered such issues in my own working life.

When asked for my opinion on complex and vaguely-regulated matters such as this, I have found it best to respond with something like "this is a particularly penumbracious area - it would probably be best to verge on the margins of prolixity in your report" - and to then skedaddle before they can work out what I've just said.

Or to boot the issues upstairs for 'clarification' - which, as often as not, will then meet with the same sort of evasive waffle.

 

[Dymanic]

I could offer an opinion if I knew the facts surrounding the question.

I'm not sure that the question can be answered solely on the basis of facts anyway. It's similar to the dilemma posed by certain problem pregnancies which may place the mother's life at risk; aborting the fetus is not as straightforward a decision as removing an inflamed appendix. Sometimes, the best interests of the patient are not the only thing to consider.

That last is actually quite an understatement. In the current environment, economics are too often the first thing that must be considered. A clinician who is under pressure from an HMO to hustle patients through the exam room in ten minutes or less is doing good to get at the salient medical facts, much less get into tricky ethical questions. A patient with minor symptoms may exert further pressure on the clinician: he wants an antibiotic. The quickest way to get rid of him may be to simply give it to him; after all, it might turn out to be bacterial. This could be confirmed by culture, but who's gonna pay for that? To withhold treatment incurs certain risks as well; a lot of folks make a good living on malpractice lawsuits. When the end result of all this is antibiotic resistant pathogens, who is responsible?

The question about antivirals might be restated as: would you prescribe any drug knowing that doing so is likely to contribute to the problems we're already having with resistant pathogens, and might not be of much benefit to the patient anyway? If the answer is no, the next question is: would you hold to this policy even if it compromised you professionally?

So, what was Phaedrus' answer?

My favorite answer is: no, we merely need someone to show us that we already know.

 

[Slimething]

In the U.S. most Physicians do not sell medications.

To point out this again and more generally:

Physicians commonly do not sell prescriptions.

Gurdur, is skeptidoc your sock? That would explain a lot about the reception skeptidoc has gotten here from other members who are health professionals.

 

[Slimething]

That last is actually quite an understatement. In the current ... When the end result of all this is antibiotic resistant pathogens, who is responsible?

Dynamic, from the style and content of what you write, I take it you are a physician. If so, I can only tell you that I would dread being in your shoes sometimes. Yes, I face ethical problems sometimes but my decision do not result in any meaningful change in anyone's lives. As far as the more difficult choices you have to make, I, like Phaedrus, can be of little help.

If the answer is no, the next question is: would you hold to this policy even if it compromised you professionally?

I read the Hippocratic Oath after your first answer and some of the versions I read were a bit nebulous as to whom you "would do no harm". I would probably tell my patient no and tell them the reasons. If the patient was intelligent, they would understand. If not, let natural selection take its course. (Isn't that truly horrible? Maybe that's why I'm not a physician!)

 

[Skeptic Ginger]

I imagine it was posted in a physician's only listserve because the question only pertains to real physicians. So what's your point in asking us?

Skepticdoc has his own secret "Dr only" forum on the Skeptic forum user groups. My guess is no one posts there. He gets bored.

While I was over there looking for a link to the user groups I came across this thread on the MSNBC article on how long cells really live after the heart stops and that brain cells die when the O2 returns. Skepticdoc made more classic comments implying once again only doctors know anything....NOT!