Many of us have encountered a friend who shares a “medical hack” when they reference that distant family member –– an uncle or a cousin –– who can prescribe them whichever medication they choose. That friend may rant or rave that whenever they are sick, “amoxicillin” or any sort of antibiotic is their panacea which cures even the most stringent of colds. However, I do not utilize the word colds lightly as that is a viral infection and many times, these medications are not utilized with the backing of the rigorous diagnostic process that a clinician performs as part of patient care. Rx has now effectively become through the family tree; instead of having the protective gutter guards that prevent one from unnecessarily taking medication, access has been expanded. This has both beneficial and detrimental impact on patient care and therefore has serious ethical implications. These implications cannot be understood without laying a simple foundation: who in the medical system is eligible to prescribe and can be deemed a “prescriber,” and what legislative stipulations and ethical obligations govern that ability? Furthermore, with the understanding of prescriptive authority, an ethical scenario, and then some legislative context, one can understand that the ethical guidelines that have been established are clear, but need additional reinforcements.
Prescriptive authority is an area of healthcare that has seen accelerated changes within recent years through the growth of physician assistants (PAs) and nurse practitioners (NPs) which have a scope of practice that has expanded and evolved over time [1]. Physicians with the highest degree of prescriptive authority are those with a Doctor of Medicine (MD) or a Doctor of Osteopathic Medicine (DO) designation as they are able to prescribe medications, including controlled substances which include medications such as opioids, stimulants, depressants, hallucinogens, and anabolic steroids [1]. Furthermore, with a Drug Enforcement Agency (DEA) license, these physicians are able to prescribe Schedule II to V medications, which are narcotics and controlled substances. The advent of the first physician assistants class formed in 1965 saw the advent of a novel healthcare professional seeking to fill the gap left by the shortage of physicians. Although state law varies, these healthcare professionals lack complete autonomy as they must be overseen by a physician. Furthermore, the advent of nurse practitioners were seen to deal with the lack of access to pediatric care [1]. Unlike PAs, NPs have greater prescriptive privileges in many states and do not require physician supervision as they are even allowed to prescribe controlled substances. With the increase in PA and NP professionals in recent years, the progressive increase in prescriptive authority has led to changing state laws to increase their autonomy in order to improve healthcare accessibility [1].
Having established those who are able to prescribe medication, diving into a simple ethical scenario is foundational for understanding the ethics of family pharmacists –– if your spouse or partner got a skin infection and needed an antibiotic, is it ethical for you to prescribe that medication to them [2]? There are serious ethical implications and under certain circumstances, it can be argued that it is ethically permissible to treat one’s family members, but in other situations it is not appropriate. Defining the ethical boundary here is incredibly important as it will come with context and provides a framework for caregivers. In emergency situations, such as a cardiopulmonary resuscitation, it is clear that a physician should treat their immediate family member without question as the emergency situation would require them to act to save a life [2]. However, this is not the situation that most ethical concerns would arise; those matters occur when symptoms are nonemergent, when a disease is out of the scope of one’s clinical skills allowing for improper diagnosis.
The Council on Ethical and Judicial Affairs of the American Medical Association determined that if the condition is only a short-term and minor problem, such as a skin infection, it is permissible for a physician to treat family members. The ethical boundary here is that the condition must be short-term, whereas long-term treatments are not permissible [3]. Furthermore, in their analysis of 400 medical staff physicians, they found that 99% of physicians had received requests from family members for medical advice or therapy with 83% of respondents reporting that they had prescribed medication for a family member, and 72% reporting that they had conducted a physical examination. This evidence shows that physicians are utilized by their families as sources of “discounted” medical care. The serious implication and problem with treating family members is the potential for personal relationships to impact treatment and determination of the optimal course of therapy for a patient to undergo [2]. In Drs. Korenman and Mramstedt’s article published in the The Western Journal of Medicine, they argued that several conditions must be met for physicians to prescribe to family members: the ailment is within the physician’s expertise, the physician should not accept any limitations on access to patient’s medical records, physicians should know enough about the method of therapy to feel comfortable with it suse, and follow-up is essential for the treatment to be successful.
These guidelines are solid, but they do not provide enough specificity into the core issue of family pharmacists –– the implication that prescriptions can be made for unnecessary or improperly used medication [4]. In some states, it is completely illegal and rightfully so for physicians to prescribe controlled substances to themselves or other immediately family members, such as North Carolina Rules 21 NCAC 32 B.1001, 32S.0212, and 32M.0109; however, the prescription medications are still legal to be prescribed to family members [5]. Many of these prescriptions can be made for patients who are receiving treatment for conditions they may not have been properly diagnosed. For instance, the friend who has a viral infection or a cold but claims that azithromycin is a panacea for all of their problems. A family member may give them an “Rx” for this medication to treat a condition which it will not even remotely improve and as a result, that patient who is effectively self-prescribing is causing greater damage and the potential generation of antibiotic resistant bacteria [6].
The ethics here are clear, but the legislation is not legally binding enough. The ethical scenarios essentially establish that patients must be in non-life threatening scenarios within a physician’s scope of reference and to where all diagnostic ability can be used. These situations are often not the contexts in which these physicians are prescribing medications, and many times these guidelines established by the American Medical Association are not adhered to [7]. The ethics here are clear, but the legislation fails to protect patients, even when they believe that a family member could be protecting them.
Greater legislative constraints must be placed on “family pharmacists.” That is where there are largely restrictions on “controlled substances” for prescribers, many other prescription medications can have harmful effects beyond just addiction which is the reason for the controlled element of many of these medications [8]. Furthermore, there needs to be some legal protection in place for physicians. In order to prescribe to family members, they must go through higher levels of approval, such as an ethics board where documentation of treating immediate friends and family members can be reviewed following treatment. The proposed regulatory process is not a slowing down of treatment, but that all of the diagnostic processes with a justification of the treatment plan must be defended under an annual review. Failure to disclose these treatments should potentially result in loss of licensure.
This may potentially seem strict and stringent to many, but I feel that given the history of the opioid epidemic and the potential negative effects of unmitigated family pharmacies that there must be additional safeguards in place. The system that I have proposed is online, the specificity of it is broad, but its intention is multi-pronged: regulate family pharmacies, protect patients, and maintain efficiency. I do not want this potential legislative action to hinder the ability of patients to receive care, but there must be a higher level of scrutiny placed upon these situations in order to guarantee that physicians are marking ethical and accurate decisions as bias is inherent in these treatment plans. I believe that the access to medicine provided through these close connections to providers can be of great benefit to patients, but that does not mean that it cannot also be of great harm. To mitigate and minimize this harm is an obligation on part of governments who are aware of these backdoor prescriptions.
Sources:
1) Zhang P, Patel P. Practitioners And Prescriptive Authority. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574557/
2) Korenman, S. G., & Bramstedt, K. A. (2000). Your spouse/partner gets a skin infection and needs antibiotics: is it ethical for you to prescribe for them? Yes: it is ethical to treat short-term, minor problems. The Western journal of medicine, 173(6), 364. https://doi.org/10.1136/ewjm.173.6.364
3) La Puma J, Stocking CB, La Voie D, Darling CA. When physicians treat their own families: practices in a community hospital. N Engl J Med 1991;325: 1290-1294.
4) Latessa, R., & Ray, L. (2005). Should you treat yourself, family or friends?. Family practice management, 12(3), 41–44.
5) Resources & Information. 2.2.3: Self-Treatment and Treatment of Family Members. (n.d.). https://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/self-treatment_and_treatment_of_family_members
6) What happens when you write rx’s for relatives | mdlinx. (n.d.). https://www.mdlinx.com/article/what-happens-when-you-write-rx-s-for-relatives/lfc-3094
7) Virtual Mentor. 2012;14(5):396-397. doi: 10.1001/virtualmentor.2012.14.5.coet1-1205.
8) The controlled substances act. DEA. (n.d.). https://www.dea.gov/drug-information/csa