Ethics of freedom to prescribe medicines
Gonzalo Herranz, department de Humanities Biomedicas, University of Navarra.
Intervention at the 5th roundtable: The Hospital Doctor and Ethics and Deontology.
I National congress of Hospital Doctors: The Hospital of the Future: Evolution or Revolution?
Palacio de Congresos y Exposiciones de Madrid, 7 March 1998, 9:00 h.
I. The ethics of freedom to prescribe medicines
II. Can the hospital adopt corporate criteria on freedom of prescription?
III. Some common misconceptions about the freedom of prescription
I will first discuss some generalities about the ethics of freedom to prescribe medicines, and then go on to consider whether the hospital as such can adopt a corporate approach to freedom to prescribe. And before concluding with a couple of conclusions, I will point out some common mistakes.
I. The ethics of freedom to prescribe medicines 
I want to start with a question: Ethically, what happens when a doctor prescribes a medicine, when he writes a prescription?
Rhetorical though it may seem, I would argue that, in the entire landscape of medical ethics, there are few questions that are more interesting. For in this seemingly simple action lies the core of the ethics of medicine.
The prescribing of prescription drugs is, in contrast to what happens with advertised medicines, a genuine medical act, in which the doctor cannot be substituted by a non-doctor. It is not a routine, subcortical act, even if it is a gesture repeated thousands of times a year, because, I insist, by writing each of his prescriptions, the doctor portrays himself as a moral agent, that is, as a free being and manager.
When it comes to prescribing medicines, one cannot separate freedom from responsibility, independence from circumspection. In 1984, the Central Commission on Deontology offered the profession a Declaration on freedom of prescription, which, almost fourteen years later, obviously needs to be updated. It contained these words which, in my opinion, are still fully valid today:
"All physicians, regardless of the modality under which they practice [...] must enjoy [...] independence with regard to the diagnosis and treatment of the patients entrusted to their care. The physician's overriding commitment is to provide his patient with the best service of which he is capable, as dictated by his professional competence and conscience [...] The physician may not alienate his professional independence in any respect. This independence is not only a right of the physician; it is, above all, a right of the patients, for the latter cannot be denied care by a physician who is competent, conscientious, and impervious to influences that may potentially harm them, whether they come from the physician's own self-interest or convenience, from administrative impositions, from family or environmental pressures, or from the ill-advised demands of the patient himself. This independence also frees the doctor from the danger of being an accomplice of the patient against the public administration or the Social Security [...]".
Thus, freedom of prescription does not exist in a libertarian space, but in a field of ethical tensions, of very well-defined responsibilities.
Firstly, from the professional skill , so closely linked today to the principles and internship of evidence-based medicine. Gone are the days of doctors prescribing by intuition, empirically, guided by pre-rational preferences disguised as "experience staff". The Anglo-Saxon codes of medical ethics state that good quality prescribing is based on criteria of appropriateness, effectiveness, safety and Economics, which requires knowledge and study: i.e. skill.
Secondly, his conscience. The doctor of good conscience is always ready to give reasons for his decisions, in a sincere, transparent, well-founded manner, goal. And, obviously, he is willing to change his prescribing habits when there are reasons to do so.
Thirdly, freedom of prescription is a right whose first holder is not the physician but the patient. The physician is free, not for his own advantage or profit, but to serve his patient with science and conscience.
Fourth, freedom of prescription is described as independence of the physician, since the physician is not a subordinate or dependent, acting at the behest of another. The physician's independence is intended to protect the patient from possible harmful influences. And, interestingly, the first harmful influences on the patient cited in the Declaration are those that could come from the physician himself: from his selfish interests, from following the line of least effort. By virtue of his freedom to prescribe, the doctor cannot compromise his independence in order to protect his possible and varied personal interests: from research scientific, from incentives from the pharmaceutical industry, from administrative impositions, from the fulfilment of objectives to which the professional degree program is conditioned, from unreasonable demands from the patient himself or his family. The doctor, we are told, cannot be an accomplice of any part of the system against any other.
At summary: by writing that little piece of paper that is the prescription, the doctor is defining himself as an ethical agent, for the prescription reflects the quality of his knowledge, the prudence of his judgement, the integrity of his character, his respect for the patient, his responsibility to the social community. And, as far as we are concerned today, a fact of great significance: his installation in the hospital.
II. Can the hospital adopt corporate criteria on freedom of prescription?
To move on, let us now also ask ourselves another question: Is the hospital ethically a nobody's house, where everyone fights for his or her own respect? Or, on the contrary, is it an ethically living and integrated organism, possessing the capacity to create ideals, to set goals, to enact rules that define its identity, to define its style and character, to seek an institutional ethos?
The question has subject enough to devote an entire congress of hospital doctors to it. But, to get out of the way, suffice it to say that, for me, a hospital is not only a group of people who have to provide concerted care to patients, for which they need to form a well-coordinated technical team. They also need to form an operational unit when it comes to defining themselves as a community that reflects and decides ethically on efficiency, equity, development, attention humanitarian, care of the internal environment, educational commitments, and so many other things that make up the diary of a true hospital.
I have argued that it is legitimate for hospitals to publicly define their ethical style. And I have pointed out that there are some issues where they are obliged to do so. Thus, a hospital can corporately establish an agreed system for the recognition, correction and prevention of the errors that inevitably occur in it; it can determine the intensity and promptness with which those who work in it are committed to respect, protect and promote the rights of patients; it can set criteria for how its physicians should relate to colleagues outside the hospital; it can, finally, define the tone of the hierarchical relationship between the organs of management and the services and Departments, and within the latter.
Returning to today's topic , I am convinced that even a hospital can, by corporate agreement , impose a specific ethical rules and regulations that prudently and fairly regulates the freedom to prescribe medicines. This rules and regulations can be arrived at by means of a simple algorithm: Is the freedom to prescribe medicines a matter of individual discretion? Or, on the contrary, is it, or at least can it be the subject of institutional study and decision? Can the hospital - or better still, can the hospital doctors agree - on an ethical rules and regulations regarding the prescription of medicines?
My answer is yes. In a hospital there should be an open and rational procedure to decide on the rational use policy for drugs and medical devices. It is legitimate for hospital doctors to establish and follow guidelines for the prescription and use of certain families of drugs. It is even obligatory for them to do so, for example, in the use of antibiotics, to avoid the nightmare of resistant bacterial strains or the chaos of improvised or insufficient treatments.
There must also be a transparent purchasing system. Hospital physicians have an obligation to pay attention to the economic aspects of medicine use and consumption: the hospital medical staff cannot be indifferent to such significant things as the employment of a unit-dose dispensing system, or the generic market. It cannot neglect to make informed and warranted decisions that contribute to cost reduction.
It must become part of the hospital's collective culture that its doctors make their clinical decisions guided by data proven. It is no longer valid to rely on intuition, anecdotal data , recent or shocking experiences, but on the rigour of what is truly proven. In this respect, clinical guidelines and protocols can be of great value financial aid , as they not only disseminate a critical sense of the value of medical interventions, but also provide data of economic interest, which is important for prescribing.
Hospital doctors also have the right and the duty to establish criteria for their relations with the pharmaceutical industry in order to protect their independence and their freedom to prescribe, and also to manage, within the high standards of law and ethics, the opportunities for continued Education , for research in clinical pharmacology, and for fair and austere ways of sponsor hospitality, travel and gifts. In the absence of such criteria, the discriminatory policy by which such fringe benefits are awarded would break the hospital into camps of hawks and doves, of the envious and the envious. A hospital cannot tolerate, without deteriorating interpersonal relations, a status of unfair abuse of one over the other.
III. Some common misconceptions about the freedom of prescription
Hospital doctors do not only prescribe for inpatients. They often prescribe for the same patients when they are discharged from hospital and for those who come to the hospital's own speciality clinics. But it is the primary care physicians who have to maintain and follow up these prescriptions. Through this mechanism, hospital doctors exert a very strong influence on primary care doctors, because it is in hospitals, and especially in teaching hospitals, that the lex artis, the correct way of practising the profession, is created, verified and confirmed. And, in particular, the way of prescribing. The conduct of hospital doctors has, for better or worse, a contagious effect on the behaviour of general practitioners.
They therefore have a duty to set an example. It is therefore necessary to review the way in which hospital doctors prescribe and the reasons for prescribing. The British Audit Commission, in its 1994 report report , states that if superfluous medicines were not prescribed in NHS hospitals, savings of 40 billion could be made; if medicines of dubious value were not prescribed, a further 8 billion could be made; and if generic medicines were prescribed, further savings of 10 billion could be made. I do not mean this as a direct or indirect allusion to the "medicamentazo". I only want to say that hospital doctors have a great responsibility on subject.
Because, if it is true freedom, freedom of prescription obliges us to be free of prejudice, to act free of bias. It is therefore inappropriate to prescribe unvalidated treatments, for the simple reason that we do not know whether they are effective and safe. Therapeutic over-prescribing is out of place, and I am not referring to that which might occur in intensive care units or in the case of terminal patients subjected to deliberately useless treatments, but to that which, encouraged by chronic prescriptions not reviewed regularly, can perpetuate aggressive polypharmacy, especially in the elderly. It must be said once and for all that there is no ethical justification for the frequent prescribing of complacency, either in hospitals or outside them: there is an ethical obligation to educate the population in health care, including the use, value and applications of medicines.
With purpose pedagogical, Anglo-Saxon codes of medical ethics tend to insist that, to be ethically correct, the prescription must be appropriate. Appropriateness is a basic ethical criterion, as it implies a considered judgement of appropriateness and circumspection. It means that the medicine is not only and in general efficient and safe, but that it is, for this patient and in view of his circumstances, appropriate. Seen in this way, appropriateness is a very broad criterion, whose implementation at internship requires science and independence, as well as weight and no small amount of moral energy.
The criterion of appropriateness will induce us to be respectful of treatment plans that have proven to be effective, not to modify them without a serious and well-founded reason. A patient who is well stabilised in his treatment should not be subjected to imprudent innovations. Freedom of prescription does not authorise frivolous changes in treatment plans. It is well known that risky situations can be created by unwise changes in medication. Risky situations can be created by trying to treat nosologically complex patients suffering from three or more simultaneous diseases at the same time and with full energy. Posological complexity can be induced when a patient is treated with more than five different medicines or has to take more than twelve doses a day. Many patients are confused and disobey the treatment plan when the doctor makes more than three changes per year in the treatment plan.
Before reaching for the prescription pad, the doctor should give it some thought. Prescribing only what is appropriate is not a matter of mere Economics. It is a matter of skill, of wisdom, of adhering to the commandment to do no harm.
Thank you very much for your attention.