The pitfalls of prescribing for family and friends

Summary

In most of Australia there is no legislation prohibiting medical practitioners from prescribing for family and friends. In South Australia it is prohibited to prescribe Schedule 8 drugs for family members unless it is a verifiable emergency.

The Medical Board of Australia states medical practitioners should avoid providing medical care to anyone with whom they have a close personal relationship. Medical defence organisations may exclude treatment of family members from doctors’ insurance cover.

Think very carefully before you prescribe for family and friends. It is only considered ethically and professionally appropriate to prescribe in exceptional circumstances, and there are potential risks to you and your family member or friend if you do.

Introduction

Prescribing for family and friends can be hazardous. Although such prescribing is not prohibited by legislation, it is not recommended by the Medical Board of Australia.

Recent cases

A doctor was found guilty of professional misconduct for providing prescriptions to her defacto partner.1 Over a period of two years, she had prescribed morphine, pethidine, psychotropic and various other drugs for her partner. The medical tribunal found that she prescribed the Schedule 8 drugs without having the proper authority, when she knew or should have known that her partner was a drug-dependent person, and that she did not maintain adequate medical records. She was disqualified from being registered as a medical practitioner for a period of 18 months.

Another case involved the death of a family friend. The 22-year-old man died four days after he had three wisdom teeth removed.2 Two days after the extraction, he was suffering from increasing pain which was not relieved by ibuprofen, or paracetamol with codeine. His mother contacted a long-standing family friend who was a GP. The GP agreed to see the man and gave him a prescription for a combination of paracetamol, codeine and doxylamine. She also gave him a box containing seven methadone tablets. These tablets were past their expiry date and had been prescribed for the GP a few years earlier after a surgical procedure. The GP wrote instructions on the box saying ‘1 tab every 6–8 hours’. Two days later, the man was found dead in his bed.

Toxicology revealed the presence of morphine, codeine, methadone, doxylamine, norfluoxetine and paracetamol. An expert opinion concluded that the death was a result of excessive exposure to methadone, most likely due to its respiratory depressant effect, or due to sudden cardiac death from fatal QT prolongation, or both. According to the expert, the major contributory factor to the toxicity of the methadone was a drug interaction with fluoxetine. The coroner found that the primary drugs contributing to the death were methadone, and its interaction with fluoxetine, and a very high dose of codeine. The coroner noted that the man’s parents and the GP were not aware that he had recently taken fluoxetine. The coroner determined that the death was preventable and referred the GP for disciplinary action.2

Legislation

Each state and territory has specific legislation that regulates the prescription of drugs.3-10 There are no legal restrictions on medical practitioners prescribing Schedule 4 drugs for their family and friends. Similarly, medical practitioners are not legally restricted from prescribing Schedule 8 drugs for family and friends, except in South Australia. There the legislation prohibits the prescription of Schedule 8 drugs for a practitioner’s spouse, domestic partner, parent, grandparent, child, grandchild, brother or sister, unless it is a ‘verifiable emergency’.11

There are also restrictions on self-prescribing. For example, in Victoria doctors cannot prescribe drugs for their own use.

Professional conduct

The Medical Board of Australia discourages all medical practitioners from providing medical care to family and friends and there is the possibility of disciplinary action. Section 3.14 of the Medical Board of Australia’s ‘Good medical practice: a code of conduct for doctors in Australia’ states:

Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because of the lack of objectivity, possible discontinuity of care, and risks to the doctor and patient. In some cases, providing care to those close to you is unavoidable. Whenever this is the case, good medical practice requires recognition and careful management of these issues.12

The Medical Council of NSW’s ‘Guideline for self-treatment and treating family members’ states:

Whenever possible, medical practitioners should not treat themselves and members of their family, because in these circumstances:

• professional objectivity may be compromised and their judgment may be influenced by the nature of their relationship with the patient

• medical practitioners may fail to explore sensitive areas when taking a medical history or may fail to perform an appropriate physical examination

• the patient may feel uncomfortable disclosing sensitive information or undergoing a physical examination when the medical practitioner is a family member

• patient autonomy may be compromised when a medical practitioner treats a member of their family

• the principles of informed consent may not be adhered to when a medical practitioner treats a member of their family.13

Specifically in relation to prescribing for family members, the guideline states:

• medical practitioners should not initiate treatment (including prescribing) for members of their family

• in emergency situations or isolated settings where there is no help available, medical practitioners may treat members of their family until another medical practitioner becomes available

• medical practitioners should not serve as primary or regular care providers for members of their family, although there are circumstances in which they may work together with an independent medical practitioner to maintain established treatment.13

It is also important to be aware that medical defence organisations may exclude cover for claims or investigations arising from elective medical treatment of a medical practitioner’s immediate family. This would include situations where a medical practitioner had electively prescribed for their family.

Prescribing for family and friends: to do or not to do?

There is limited published research on the prevalence of prescribing for family and friends. A survey of US paediatricians found that 76% had been asked to provide a prescription for a first-degree relative.14 Interestingly, 86% of the respondents reported that they had refused to write a prescription for a family member or a friend on at least one occasion. The following reasons ‘strongly influenced’ their decision to refuse a request:

• outside the practitioner’s field of expertise (88%)

• opinion that the person needed their own physician (70%)

• request not medically indicated (69%)

• need for a physical examination (65%).

If you are asked to provide a prescription for a family member or friend, it is important to ask yourself:

• Am I able to provide appropriate medical care to my family member or friend in this situation?

• Am I following my usual practice in providing a prescription or repeat prescription in this situation?

• Would my peers agree that prescribing in this situation was consistent with good medical practice?

• If I prescribe, does this mean that my family member or friend is my patient?

• Would our personal relationship survive an adverse outcome of treatment?

It is useful to consider in advance how you might refuse to provide a prescription, for example ‘professional guidelines and regulations prevent me from prescribing for you’.

Conclusion

The starting point for a request to prescribe for family or close friends should be ‘no’, unless there are exceptional circumstances. Exceptional circumstances may include an emergency where no other medical practitioner is available to assist, or providing a repeat prescription at the request of the treating practitioner. Remember you can still assist a family member or friend without getting out your prescription pad by acting as a knowledgeable guide to help them obtain the required care from their treating practitioner or another medical practitioner.