Berks County Medical Society Medical Record Spring_2018 - 16

m E d i C a l r E C o r d F E at u r E

Eschew Self Prescription
Medical Director of The Foundation's Physicians'
Health Program Shares Ethics Guidance
by Raymond Truex Jr., MD, FAANS, FACS

U

p front, I have to be honest that I looked up that word.
Eschew. It's a synonym for "avoid" or "steer clear of." I
like the way it sounds. But its meaning is clear and
unambiguous. Several times a week, when I review in depth the
terms of an advocacy agreement with a new PHP participant, I will
advise them to eschew prescribing all drugs for themselves and for
their family. This is one of the things participants must agree to and
sign. Intuitively, I understand why physicians who may be addicted
to mood-altering drugs should avoid self-prescribing, because they
hold the key to the candy store. And as a surgeon, I understand the
admonition against operating on a member of my immediate family;
would I have the emotional self-control to successfully deal with a
life-threatening complication, such as a major hemorrhage, if the
person laying on the operating room table before me was my wife or
my child? The need to avoid that scenario is easily understood.
But then I began to consider further what I was requesting of the
participant. Why avoid prescribing for family? What's wrong with
prescribing a Z-Pak for your teenage child with bronchitis? What do
medical ethics say about this practice?

The very first code of medical ethics drafted by the American
Medical Association (AMA) in 1847 recommended against
physicians treating family members. Their ethics state that "the
natural anxiety and solicitude which he experiences at the sickness
of a wife, a child ... tend to obscure his judgement, and produce
timidity and irresolution in his practice." (1) This ethical position was
reaffirmed by the AMA in 1993 and continues to the present.(2)
Further, the American College of Physicians recently stated that
physicians should "usually not enter into the dual relationship of
physician-family member or physician-friend."(3) The American
Academy of Pediatrics position is similar: "Caring for one's children
presents significant ethical issues."(4) The exception to this rule is
during emergency situations during which no other physician is
available, and then only for a limited period of time.(5)
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Requests to treat family and friends are pervasive, and physicians
often feel pressured and conflicted when asked to do so. A 1991
survey reported that 99 percent of physicians had received requests
from friends or family for medical advice, diagnosis, or treatment,
and 83 percent had prescribed medications for relatives.(6)
Usually, these requests are for minor illness or injury, and
antibiotics, contraceptives, and analgesics are the most commonly
prescribed classes of drugs in these circumstances. But occasionally
physicians will go farther out on the limb to prescribe sedatives,
antidepressants, and narcotic analgesics.(7-9) In another study, 15
percent of hospital physicians reported serving as an attending for
a loved one, and 9 percent had performed elective surgery on a
relative.(6) It is not surprising to me that physicians, an intelligent
but self-willed and independent group, will not infrequently choose
to go against the grain of ethical recommendations. Or more
generously, perhaps they are simply unaware of the ethical guidelines
- I don't recall any training about these issues in medical school
(albeit a long time ago).
Here are some of the pitfalls of caring for family and friends:
failure to ask sensitive but important questions, failure to do a
complete physical examination, failure to keep adequate records
of medical care, failure to provide alternative plans of treatment,
failure to obtain medical consent, providing care outside the scope
of clinical expertise, failure to communicate with the physician
of record, and failure to obtain informed consent in the case of a
minor(5). Also, difficult situations may arise in case of a complication
which occurs as the result of a physician treating a friend or family
member, including remorse on the part of the physician, and anger
on the part of the family member or friend, leading to medical
malpractice action or reporting of the physician to his state's Medical
Board.(5) Finally, Medicare prohibits payment for services ordered or
performed by a provider for a family member.(6)


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Berks County Medical Society Medical Record Spring_2018

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