Ethical Considerations When Prescribing for Friends and Family

Psychiatrists, like many physicians, may struggle to balance our wish to be helpful with the requirement to maintain appropriate boundaries and practice standards. In particular, it is challenging to respond to requests by friends and family to address medical problems or write prescriptions. Regardless of whether the issue is within our scope of practice, it can be tricky to withstand the urge to do the doctorly thing with people who are not our patients. After reviewing the applicable legal standards, this article will discuss relevant ethical concepts and apply them to some common scenarios.

Each state has its own legislative code regulating the practice of medicine; all require physicians to adhere to standards of care. The Colorado Medical Practice Act includes in its definition of unprofessional conduct, “Any act or omission which fails to meet generally accepted standards of medical practice.” This suggests that if you treat a family member or friend, you must adhere to the same standards as usual, including ordering any necessary tests and documenting your exam and medical decision making.

It also asserts, “Prescribing, distributing, or giving any controlled substance to oneself or family members, except in an emergency, is considered unprofessional conduct and grounds for disciplinary action.” Therefore, even if you do an appropriate evaluation and keep a medical record, it is not legal to prescribe sedative hypnotics, anxiolytics, or narcotics to yourself or family members outside of an emergency.

The DEA Practitioner’s Manual reinforces this latter rule: “To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.” Casually prescribing Ambien for your spouse or yourself falls outside this guideline and risks running afoul of the DEA and your state-licensing board.

While state and federal law instructs us to uphold the same standards of care in all our practice settings, even the casual ones, and prohibits us from prescribing controlled substances to family members, these laws don’t address all the scenarios in which we may consider prescribing to people who are not our formal patients. Two ethical concepts are particularly useful in these instances: beneficence and fiduciary duty. Beneficence is the familiar principle that our professional actions will benefit the patient. Fiduciary duty is the requirement that physicians consider only the interests of the patient, not the physician’s own interests, in the practice of patient care. When faced with a request to prescribe for a friend or family member, we might ask ourselves, “Is my decision to prescribe based on what will be most medically beneficial to this person or is it based on other factors, such as convenience or the desire to appear helpful in others’ eyes?”

When your mother, visiting for the holidays, runs out of her antihypertensive and the pharmacy is going to close before your mother can get a call back from her primary care physician (PCP), it will certainly be beneficial to your mother for you to call in a prescription. The potential harms of waiting for her PCP to take care of this on a holiday weekend, perhaps missing several doses of a vital medication, are more compelling than the fact that you have not seen her as a formal patient and do not regularly prescribe antihypertensives.

To satisfy the requirement that you adhere to the usual standards of care, it would be wise to record her blood pressure and heart rate and to send a letter to her PCP for inclusion in your mother’s medical record documenting this limited exam and the prescription. With this, you are behaving much as any covering colleague would be renewing a stable prescription and documenting it in the medical record.

If your neighbor’s child appears to have symptoms of otitis media, you may be asked to call in a prescription for an antibiotic. At first glance, it could appear that this is beneficent, but that is true only if you are providing the same level of care as a pediatrician. Does your otoscope still work? Are you confident you can interpret what you see through it? Have you kept up on the latest American Academy of Pediatrics guidelines for the treatment of otitis media? If your examination and treatment of the child fall below the standard of care, you are not maximizing beneficence. Your fiduciary duty to the child requires you to seek the best level of care, not do the thing that is most expedient for your neighbor. Going to the pediatrician’s office or urgent care center is time consuming and costly, but it ensures appropriate medical care. If you do decide to prescribe that antibiotic, you should create a progress note documenting the symptoms, the exam, and the medical decision making.

Although prescribing an antibiotic for a presumptive ear infection will not by itself draw the attention of the licensing board, a pattern of casual prescribing does attract scrutiny, and boards do take disciplinary action based on physicians’ regularly practicing outside their area of expertise or their usual practice settings.

As a general rule of thumb, when I am outside my office, I am happy to render an opinion about whether that rash looks like something serious or whether the cough sounds bad enough to warrant a visit to the doctor. In this way, my friends and family can benefit from my medical education, but I stop short of providing actual treatment. This ensures appropriate boundaries, protects my license, and averts the incredible pain that would ensue if my medical decision making were wrong and I inadvertently harmed a loved one I had intended to help. ■