Commentary

This case considers the physician’s central obligation to the individual patient along with the physician’s -- and the profession’s -- broader obligations to society and to other patients. Ms. Carr is a well-meaning patient seeking help from a busy physician for a routine acute illness. Applying commitments such as the primacy of patient welfare, social justice, and physician stewardship of resources -- all important aspects of medical professionalism embodied in our ethical obligations^[1,2] -- can be challenging in such circumstances. Inevitably, the uniqueness of the individual patient and the physician’s experience and judgment in weighing the uncertainties will (and arguably should) inform how the physician comes to an agreeable, ethical decision with the patient. The goal is to meet the patient’s needs while ensuring professional integrity and meeting the physician’s responsibility to be a good steward of resources.

The clinical facts of the case suggest that the patient has uncomplicated, probably viral, pharyngitis. Clinical indications (presence of exudate, no anterior adenopathy, presence of cough, and age), suggest that her chances of having bacterial pharyngitis are not zero but are probably less than 10%. Applicable guidelines^[3] would recommend only symptomatic treatment with no further testing or prescription medication (rapid strep testing, throat culture, or antibiotics). Of course, her symptoms could evolve, but information about that is not provided in the case. All other things being equal, therefore, the clinical facts would prompt most physicians to hold off on antibiotics at present, encourage symptomatic treatment, and encourage re-evaluation if symptoms evolve, an approach that is in the best interests of both the patient and the community.

However, the case is not quite that easy. The patient plans to fly notwithstanding the risk for barotrauma, and she expresses a legitimate worry about symptom progression and the finite possibility that she in fact may have (or may develop) strep throat. Consideration of the patient’s values and circumstances is an important feature of shared decision-making and is consistent with principles of evidence-based medicine.^[4]

The case also poses questions about how much to accommodate patient wishes for treatments with little or no prospect of benefit. It is fairly clear that Ms. Carr would not benefit from antibiotics, but she wants treatment or at least a prescription to take with her. Acceding to her request not only may result in nonbeneficial treatment but poses real (but not huge) risks to her and to public health. She could experience adverse effects, such as vaginal yeast infection, Clostridium difficile colitis, or increased propensity for colonization with community-acquired methicillin-resistant staphylococcus. Moreover, taking a routine but unneeded antibiotic contributes one more episode of selective pressure in the constant evolution of bacterial pathogen resistance. When there is reason to believe that the patient might benefit, the risks associated with antibiotics are tolerated in the belief that the real benefits of treatment outweigh the potential harms. But when the prospects of benefit recede, inappropriate use of antibiotics can (and, in this case, does) lead to an unfavorable risk/benefit ratio. Offering her a “wait and see” antibiotic prescription for self-treatment if her symptoms evolve, a common “compromise” strategy, is also not straightforward because from a symptom perspective, viral pharyngitis evolves very similarly to bacterial pharyngitis.

The Physician Charter on Professionalism^[1] and the American College of Physicians’ Ethics Manual, sixth edition,^[2] offer important guidance that places the patient and the patient’s needs at the center of medical decision-making but is sensitive to the appropriate stewardship of medical resources for society in meeting individual patient needs.

Both the Physician Charter and the Ethics Manual hold that the physician’s primary commitment must always be to the patient’s welfare and best interests. The commitment to act for the good of the patient despite market forces, societal pressures, and administrative exigencies is a form of altruism that contributes to the trust that is central to the patient-physician relationship.^[1,2] Acting in the patient’s best interests requires that the physician understand the patient’s health problems, concerns, goals, and expectations. The physician’s obligation is to consider patient’s values and preferences while protecting the patient’s health-related interests.^[5]

In addressing the patient’s concerns, however, the physician is not required to violate fundamental personal values, standards of medical care or ethical practice, or law.^[2] Nor is a physician obligated to provide all treatments and diagnostics without considering their effectiveness.^[2] The Physician Charter recognizes patient autonomy as a fundamental principle of the medical profession and holds that “patients’ decisions about their care must be paramount as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.”^[1] Patient autonomy does not confer an unqualified right to a treatment and should not be used to justify acquiescing in patients’ requests for nonbeneficial treatments.^[5] Ideals of professional integrity require the physician to promote coherent deliberation with the patient about what is the best care for the patient.^[5]

Healthcare takes place in a context beyond the patient-physician relationship.^[2] In upholding their primary obligation to the patient’s welfare, physicians are required to provide healthcare that reflects the wise and cost-effective management of limited clinical resources.^[2] The Ethics Manual states: “As a physician performs his or her primary role as the patient’s trusted advocate, he or she has a responsibility to use all health-related resources in a technically appropriate and efficient manner.”^[2]

The fact that a given test or treatment is expensive does not in and of itself disqualify it from being an ethical option. Neither does the fact that a particular treatment is inexpensive (eg, generic penicillin) necessarily constitute good stewardship, particularly when issues such as preserving antibiotic sensitivity are at stake. Whether an underinsured patient asks for expensive therapy that is indicated or a self-paying billionaire asks for inexpensive therapy that is not indicated, the same principles apply. Physician and patient should collaboratively assess the patient’s wants and needs. Then the physician should propose effective therapies that would be a prudent clinical and empathetic first step to addressing the patient’s needs.

The principle of social justice requires physicians to promote “the fair distribution of health resources”^[1] and “the life-enhancing opportunities afforded by health care.”^[2] The provision of unnecessary treatments and services exposes patients to avoidable harm and expense while diminishing the resources available for others.^[1] As stated in the Ethics Manual, “Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”^[2]

How should a physician in a circumstance like that of Dr. Trainer approach Ms. Carr’s request? Ms. Carr conveys a common lay belief that viral upper respiratory tract infections can “turn into” bacterial infections that necessitate antibiotics. She requests that Dr. Trainer provide her with a prescription for antibiotics just in case. Professionalism is not always synonymous with the customer service concept encapsulated in the phrase “the customer is always right,” especially when potential patient and community harm are at stake. In fact, there are times when acquiescing to patient wishes jeopardizes a physician’s primary ethical obligation to the patient’s welfare.^[5] Arguably, this is one of those occasions.

Common sense must guide when and if a particular expensive therapy is warranted. Material considerations include treatment effectiveness, cost, patient needs, special circumstances for disadvantaged groups, and the availability of alternatives.^[6] When such treatments are warranted medically and comport with the patient’s values, physicians can rightly advocate for those expenditures regardless of a patient’s financial or insurance situation.^[2] However, in circumstances such as those in this case, where evidence does not support a particular therapy^[3] and tests or treatments are unlikely to contribute to the patient’s welfare, the physician must fulfill his or her commitment to the patient’s best interests by exercising evidence-based restraint while addressing the patient’s needs. In this case, the use of an antibiotic offers no reasonable expectation of benefit but does have the potential for harm to the patient as well as to the broader society, suggesting an unfavorable risk/benefit ratio.

Admittedly, it might be easier and quicker simply to prescribe an antibiotic and move on to the next patient. A national survey of internists found that in the previous month, 1 in 8 had prescribed antibiotics primarily to promote positive patient treatment expectations.^[7] However, being a professional means putting patient care above self-interest, sometimes at the expense of convenience or the desire to please patients. Professional integrity requires the physician to respond to the patient’s needs and decline requests for inappropriate care.

In instances of disagreement between patient and physician, the physician has an obligation to explain the basis for the disagreement, to educate the patient, and to meet his or her need for comfort and reassurance.^[2] Sometimes more work needs to go into understanding the nature of the disagreement as is frequently the case in end-of-life care.^[8] Meeting a patient’s needs may sometimes require more deliberate and in-depth inquiry about what the patient’s real needs are, including needs for reassurance and access to care if the illness progresses. It may require re-imagining the full range of tools at the physician’s disposal to reassure, clarify, and at times reframe the patient’s understanding of what her needs are. It does not require inappropriate prescribing of ineffective or potentially harmful treatment.

Is it appropriate it to give a “wait and see” prescription? Routinely doing so for antibiotics not only risks the potential harms for the patient and for society previously discussed but also creates, or at least could reinforce, the common cultural belief that antibiotics are effective in viral upper respiratory tract infections The cumulative impact of this seemingly benign approach challenges the physician’s role as a wise steward of healthcare resources. Routinely engaging in this practice would be difficult to justify under the standards of professionalism and ethics in the Physician Charter on Professionalism and the sixth edition of the American College of Physicians’ Ethics Manual.

Addressing Ms. Carr’s worries, misunderstandings, and uncertainties requires the virtues of compassion, courage, and patience. The tried and true methods of effective and empathic communication are essential here. They do not call for a prescription.

Acknowledgments: The ACP Ethics, Professionalism and Human Rights Committee would like to thank Jon C. Tilburt, MD, Lois Snyder, JD, Michele Mathes, JD, and Daniel Sulmasy, MD, PhD, authors of the case history and commentary, and J.C. Duffy, illustrator. This case study has been developed under a Putting the Charter into Practice grant from the American Board of Internal Medicine Foundation. The ACP Center for Ethics and Professionalism and the ACP Ethics, Professionalism and Human Rights Committee gratefully acknowledge the Foundation’s support.