This interaction involves a situation in which a physician allowed a compromise of professional boundaries in several ways. He acquiesced to a patient’s inappropriate requests for narcotics, and he entered into a romantic relationship with the patient. In the end, the physician paid a great price for his actions.
Improper prescribing of pain medication
Four Basic Principles of Medical Ethics4
- Beneficence — acting for the patient’s good
- Nonmaleficence — doing no harm
- Autonomy — recognizing the patient’s values and choices
- Justice — treating patients fairly
A 28-year-old female patient presented to an FP with complaints of throat and back pain. The physician prescribed clarithromycin for pharyngitis and oxycodone for the patient’s back pain. Although the patient was asked to sign a contract to receive the oxycodone, neither the patient nor the physician honored the terms of the contract. Shortly after the patient was first seen in the office, the physician entered into a romantic relationship with her. He continued to treat the patient for back pain, giving multiple prescriptions and sample medications. Not all the prescriptions were recorded in the patient’s medical record, and several were written in the name of the patient’s fiancé, who was not the FP’s patient. The physician provided numerous narcotic pain medicine prescriptions over the course of eight months’ time. After eventually discovering that this patient was obtaining additional pain medication from other physicians and acknowledging to himself that she was manipulating him, the FP ended his personal relationship with the patient and discharged her from his practice. Shortly after the FP broke up with her, the patient sued him, alleging improper prescribing of pain medications resulting in her addiction. Experts agreed this physician’s care was below the standard, and the case was ultimately resolved short of trial. In addition, the physician had his license revoked by his state’s medical board.
More Information About Medical Ethics and Physician-Patient Encounters
- Closed Claim Case Study: Patient Demand for Unconventional Care Presents an Ethical Dilemma for Physicians
- Closed Claim Case Study: When Patients Refuse Treatment: Medical Ethics Issues for Physicians
- Closed Claim Case Study: Patient Confidentiality: Understanding the Medical Ethics Issues
- Closed Claim Case Study: Cultural Bias in Health Care Delivery Causes Communication Problems and Poor Outcome
- Closed Claim Case Study: Medical Ethics Issues with Shared Decision-Making in Patient Encounters
- Closed Claim Case Study: Improper Informed Consent Leads to Allegation of Negligent Supervision
- Closed Claim Case Study: Ethical Dilemmas with Disclosing Medical Errors
The main ethical principle that applies to this case is nonmaleficence. The physician violated this principle by taking actions that increased the risk of harm to his patient. His romantic relationship with the patient prevented him from being objective about her condition and from recognizing her addiction. He was willing to give the patient inappropriate prescriptions. The FP abandoned his professional responsibility and allowed the patient to call the shots. This was not respect for her autonomy, however. What the patient was asking for was not accepted medical treatment, and, as Jonsen and colleagues affirm, “Patients have no right to demand that physicians provide medical care that is contraindicated.”1 Mahowald agrees. Her third guideline, “the interest of others may outweigh respect for patient autonomy,” refers to situations in which “the interests of the family or physicians may be more compelling. For example,” she states, “if a patient requests treatment that is not medically indicated, the physician is not obligated to provide it.”2 The patient was exploiting this physician to obtain narcotics; however, the physician strayed so far from suitable ethical and legal boundaries that he could not defend against the malpractice allegations, and he was compelled to forfeit his medical license.
Risk Management Recommendations — Interactions in which Boundaries Could Be Compromised
- Strive to provide objective examinations for all patients.
- Recognize that as a physician, your professional responsibility includes a duty to care for patients and to maintain appropriate boundaries.
- Do not allow friendship with or manipulation by a patient to influence your adherence to the standard of care.
- Avoid flirtatious behavior and keep patient communication focused on the evaluation of medical symptoms and the discussion of treatment options.
- Do not enter into romantic or sexual relationships with patients. The primary reason “for this hard and fast rule is that the physician’s position of authority and the patient’s position of vulnerability raise the risk of exploitation.”3
- Speak frankly with the patient and document concerns if he or she is exhibiting drug-seeking behavior such as requesting refills too frequently or making visits to the emergency department and complaining of pain.
- Do not prescribe a controlled substance unless there is a legitimate medical purpose.
- Take a medical history from a patient who has presented with a complaint of pain, and establish a logical connection between the complaint, the medical history, the physical examination and the drug you are prescribing.
- Consider using a pain medication agreement with patients who are taking opioid medications. Pain medication contracts generally call for a patient to agree to obtain pain medication only from you and to take the medication as prescribed.
- The contracts help you and patients define and agree on appropriate behavior, and they hinder patients from obtaining large quantities of drugs.
- Keep thorough records. Obtain and document a thorough patient history, including possible or potential illegal drug use or abuse. Document all medications prescribed. Document the rationale for medications prescribed as well as treatment plans and goals.
- Re-evaluate and document the patient’s level of pain and response to treatment at each visit.
1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:98.
2. Mahowald MB. Bioethics and Women: Across the Life Span. New York, NY: Oxford University Press; 2006:18.
3. Rubin EB. Professional conduct and misconduct. Handbook of Clinical Neurology. 2013;118:91-105.
4. Beauchamp TL, Childress JF. Part II: moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press;2012:99-288.