Farber, Neil J. MD; Cederquist, Lynette MD; Devereaux, Mary PhD; Brown, Ed MD
The increasing use of sildenafil citrate (Viagra) to treat erectile dysfunction presents physicians with ethical challenges.1 Among these are conflicts between physicians' professional obligations to treat individual patients and a variety of “extratherapeutic” factors that may make them reluctant to meet their role-related obligations. These extratherapeutic factors are not related to the health of the individual patient; they may involve the effect of the treatment on the health of other individuals such as the patient's present or future sexual partners. These external factors are heterogenous but form a natural group in that they affect the prescribing of sildenafil in ethically interesting ways.
When there is a professional obligation to treat erectile dysfunction in a high-risk patient, the ethical challenge is generally framed as a conflict between the physician's duty and the physician's conscience. However, this oversimplifies the problem by conflating three issues that should be distinguished: the physician's duty to treat in conflict with the physician's public health concerns (the patient poses a danger to society or others), private moral concerns, or bias against homosexuality and/or HIV-infected patients.
Among men who have sex with men, the use of sildenafil has been found to correlate with an increase in the number of sexual partners2 and with higher levels of unprotected sex.3 Studies have demonstrated the increasing ingestion of sildenafil for sexual performance enhancement (often misleadingly called “recreational” use)4 and its connection with illicit drugs.5,6 These findings indicate that sildenafil use may have a negative effect on public health. In addition, research has shown that, compared with other men, men who use drugs to treat erectile dysfunction have higher rates of sexually transmitted diseases, particularly HIV infection.7 Awareness of these adverse effects may lead residents and other health care providers to question prescribing sildenafil to some patients, even where its use is medically indicated. Physicians may therefore face a conflict between competing professional obligations: those to the patient versus those to society or public health. In certain cases, consideration of the health of persons other than the patient may constitute legitimate grounds for physicians to withhold sildenafil prescriptions.
Physicians' private moral considerations constitute a second source of potential conflict in their decisions about whether to prescribe sildenafil. These reflect personal concerns with the moral character of patient behaviors, such as adultery, apart from the consequences of these behaviors (i.e., their effect on the patient's sexual partners or on the general public health). Conflicts between physicians' personal values and professional obligations have been widely discussed in the medical literature. For example, despite clear ethical guidelines, some physicians are unwilling to refer patients to colleagues who will provide services they do not approve of (e.g., terminal sedation, abortion in cases of failed contraception, prescriptions of birth control to adolescents without parental consent).8 These types of moral concerns do not constitute legitimate grounds for physicians to withhold sildenafil where it is medically indicated.
Bias against homosexuals or HIV-infected patients is a third potential source of conflict and must be distinguished from legitimate concern for protecting a patient's sexual partners or the public health. Bias also needs to be distinguished from private moral concern about particular behaviors, although neither constitutes a legitimate reason for withholding medical treatment. Although the medical obligation to treat does not vary with the patient's sexual orientation, evidence suggests that medical providers at all levels are potentially subject to bias. A 1986 study of California physicians that was conducted prior to the early misapprehension that AIDS was a disease limited to homosexual individuals nonetheless found evidence of hidden and overt homophobia and related attitudes.9 These perceptions ranged broadly according to year of medical school graduation and specialty, with more recent graduates reporting greater comfort caring for homosexual patients, but a 1987 study reported very negative and prejudicial attitudes toward AIDS and homosexual patients even among medical students.10 No studies since that time have demonstrated similar biases against homosexuality among physicians. However, provider bias—defined here as conscious or unconscious hostility, fear, contempt, or hatred of groups of individuals—has a demonstrated impact on the quality of medical care, eroding the patient's right to receive respectful, compassionate care.11,12 It may also undermine the physician's sense of obligation to provide such care or even to treat certain patients.
Despite sildenafil's possible effect on the rates of sexually risky behavior, to our knowledge no study to date has examined physicians' attitudes toward prescribing sildenafil and related drugs in ethically challenging situations. We therefore conducted this study to examine residents' decision making in ethically challenging situations involving requests for sildenafil from hypothetical patients. These scenarios included patients with varying degrees of risk in their sexual behavior, with or without HIV infection, and with homosexual or heterosexual orientation. We also explored whether residents would be less likely to prescribe sildenafil to men who engaged in adulterous behavior than to those in monogamous relationships. In addition, we considered whether certain values and attitudes held by residents would affect their decision making in these scenarios.
In September through November 2009, we surveyed all 128 internal medicine and family medicine residents at the University of California, San Diego (UCSD), School of Medicine to determine how likely they would be to prescribe sildenafil in a variety of ethically challenging hypothetical scenarios. The chief residents of both residency programs distributed the anonymous written questionnaires to residents in their ambulatory clinics as well as during lectures and other gatherings such as grand rounds. One month after the initial distribution, the chief residents made follow-up phone calls to nonrespondents to remind them to complete the questionnaires, and two weeks later, a second copy of the questionnaire was mailed to nonrespondents. Chief residents collected all surveys from the respondents and then delivered them to one of the authors (N.J.F.) for data analysis. This study was approved by the UCSD institutional review board.
The survey presented 10 hypothetical scenarios in which patients presented with erectile dysfunction (for the full survey, see Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A62). Residents were asked to indicate how likely they would be to prescribe sildenafil in each scenario, using a four-point Likert-type scale (very likely, likely, unlikely, very unlikely). Three nested variables were included in eight scenarios:
* high-risk sexual behavior (multiple sexual partners, anal intercourse, without using condoms) versus low-risk sexual behavior (one sexual partner, only safe sex practices, always using condoms);
* HIV-positive versus HIV-negative status; and
* homosexual versus heterosexual identity.
Two of these scenarios included low-risk, HIV-negative, adulterous relationships (one heterosexual, one homosexual), which we compared with two additional scenarios involving low-risk, HIV-negative, monogamous relationships (one heterosexual, one homosexual).
The residents were also asked to indicate the degree to which they agreed with the following four attitudinal items, using a four-point Likert-type scale (strongly agree, agree, disagree, strongly disagree):
* A patient's right to medical treatment should have priority over a physician's conscience.
* Patients who have low morals do not have the right to demand medication for erectile dysfunction.
* Protecting society is more important than respecting an individual patient's right to medical treatment.
* In some circumstances, a physician has a professional obligation to protect a patient from his or her own risky behavior.
In addition, the survey requested demographic information, including residents' specialty.
The survey was pretested for face and content validity among 25 faculty members of the Division of General Internal Medicine/Geriatrics at the UCSD School of Medicine. This feedback was used to clarify the wording of some scenarios prior to survey administration.
One of the authors (N.J.F.) entered the data from the completed surveys into ProStat version 3 (Poly Software International, Pearl River, New York), which was the program used for all data analyses. He collapsed residents' responses to the hypothetical scenarios into two categories (very likely/likely versus very unlikely/unlikely) and did the same for the attitudinal question responses (strongly agree/agree versus strongly disagree/ disagree). The responses on each of the four variables (risk, HIV status, sexual orientation, and adulterous versus monogamous relationships) for which respondents were likely or unlikely to prescribe sildenafil were analyzed via Student's t tests, comparing presence and absence of the variable (high risk versus low risk, HIV positive versus HIN negative, homosexual versus heterosexual, and adulterous versus monogamous). We calculated as a separate variable the total number of scenarios for which respondents were likely/very likely to prescribe sildenafil. We used Kendall–Tau and multiple logistic regression analyses to assess the association of demographic variables with the number of scenarios for which the respondents were likely/very likely to prescribe sildenafil. We considered P values <.05 to be significant.
Of the 128 residents surveyed, 81 (63%) responded. Table 1 shows respondents' demographic data and attitudes about physicians' responsibilities and societal values. Responding residents had an average age of 29 and were fairly evenly divided between men (43/81; 53%) and women (37/81; 46%). There were similar response rates across all three postgraduate years (PGYs) of the residency programs (PGY 1: 27/48 [56%]; PGY 2: 22/40 [55%]; PGY 3: 31/40 [78%]). More internal medicine residents than family medicine residents responded, but the internal medicine residency is significantly larger. Therefore, the response rates for internal medicine (64/105; 61%) and family medicine (16/23; 70%) were approximately the same.
With regard to the attitudinal items, respondents tended to disagree that patients with low morals have no right to erectile dysfunction medication (69/81; 85%) and to agree that the patient's rights are more important than the physician's conscience (59/81; 73%). However, they agreed that protecting society is more important than respecting an individual's rights (49/81; 60%), and they agreed that in some circumstances the physician has an obligation to protect the patient from his or her own risky behavior (70/81; 86%).
Table 2 shows residents' responses to each of the 10 hypothetical scenarios. Respondents were significantly more likely to prescribe sildenafil to hypothetical patients who posed low risk to their partners than to patients who engaged in high-risk behaviors (P < .0001; Figure 1). Whereas the results showed no difference between scenarios with homosexual and heterosexual patients, respondents were significantly more likely to prescribe sildenafil to patients who were HIV negative than to those who were HIV positive (P < .0001; Figure 2). This difference was seen even in situations where there was little risk (homosexual patients, P = .04; heterosexual patients, P < .001). In scenarios with little risk and in which the patients were HIV negative, residents were significantly less likely (P < .0001) to prescribe sildenafil to hypothetical patients engaging in adulterous relationships (homosexual patients, 65/81 [80%]; heterosexual patients, 64/81 [79%]) than they were to prescribe sildenafil to those who were monogamous (homosexual patients, 76/81 [94%]; heterosexual patients, 78/81 [96%]).
Likelihood of prescribing sildenafil was associated only with the resident's attitude about physicians' professional obligation to protect patients from their own risky behavior (Table 3). Those residents who agreed with this attitudinal item were likely to prescribe sildenafil in fewer scenarios than those residents who disagreed with the statement (P = .005). No other demographic or attitudinal factors demonstrated an association with the number of residents likely to prescribe sildenafil.
Individual physicians have personal biases and values that are based on their prior personal experiences and cultural upbringing. Professionalism enables them to put those biases aside and explore with the patient the diagnostic and treatment options that best meet the patient's needs while taking the patient's personal story into account. But physicians lack guidance on how they should make decisions with their patients when an ethically challenging situation arises.13
In this study, internal medicine and family medicine residents at the UCSD School of Medicine made decisions about prescribing sildenafil in ethically challenging hypothetical situations based on several “extratherapeutic” factors. The most influential of these factors was the risk posed to the patient's sexual partners. This indicates that residents felt the need to weigh their professional obligation to respect the right of the individual patient (to have the sildenafil prescribed) against their obligation to protect innocent others (unsuspecting sexual partners). In practice, physicians with HIV-infected patients who are unwilling to disclose their HIV status to their sexual partners are confronted with similar ethical challenges—namely, determining the justified limits of doctor–patient confidentiality and, perhaps, expanding the decision-making process to include the interests of sexual partners.1 To face these challenges, residents and medical students need direction about how to weigh risk to society against individual rights. Participating in case conferences is one means by which trainees can learn to balance these competing ethical values.
The residents in this study demonstrated no bias based on the sexual identity of the patients presented in the scenarios. This is encouraging and may reflect progress since studies done in the late 1980s and early 1990s.8–10 However, respondents were less likely to prescribe sildenafil to HIV-positive patients than to those who were negative for HIV, even when the hypothetical scenario was low risk (patients used safe sex practices and condoms). Residents and medical students need to be taught that their decision-making approach should be the same for patients who are HIV positive as for patients who are HIV negative.
Residents in this study also may have been influenced by their personal moral convictions. Respondents were less likely to prescribe sildenafil to hypothetical patients who engaged in adulterous relationships than to those who did not, even when the adulterous patients were HIV negative and engaged in safe sex practices that included the use of condoms. We did not separately assess the residents' attitudes about adulterous behavior and morality, and their moral objection to infidelity is a supposition. However, the residents' attitudes may reflect the growing incidence of pharmacists and other health care professionals refusing on personal moral grounds to provide medical services “ordinarily required of the profession”14 (e.g., emergency contraception, abortion, infertility treatments) or to forego treatments unwanted by patients. Discussions with residents and medical students should raise the issue of managing conflicts between their personal moral convictions and patients' rights.
Some have argued15 that medicine has shifted away from the practice of paternalism, in which physicians make decisions for patients without informing them of options or allowing them to participate in the decision-making process. However, in this study, the only factor associated with the number of scenarios in which residents were likely to prescribe sildenafil was residents' endorsement of the physician's obligation to sometimes protect patients from their own risky behavior—basically an expression of paternalism. In the United States, medical paternalism has officially given way to the more ethically acceptable concept of beneficent persuasion,15 which is more congruent with patient-centered health care. Beneficent persuasion means discussion and collaboration with an active exchange of ideas and the sharing of power and influence between doctor and patient with the goal of serving the patient's best interest. This implies a balance between the model of physician paternalism with its presumed “beneficent intent” and the “consumer medicine” mode of decision making in which patients choose diagnostic and therapeutic options without physicians' experience. Residents and students need to understand that beneficent persuasion is the predominant method used in the treatment of patients. They should be educated about shared decision making and learn that paternalism does not promote a patient-centered approach to medical care.
This study has several limitations. It was conducted in two residency programs at one university medical center. Further studies of other types of residents who may prescribe sildenafil and at other institutions are warranted. In addition, this study was not intended to reflect what residents might actually do in practice. Residents are very unlikely to encounter the situations hypothesized in the survey instrument, and, in actual patient encounters, there may be additional forces at work (e.g., patient expectations, negotiation).
In summary, residents in this study considered hypothetical scenarios to determine whether to prescribe sildenafil to patients with erectile dysfunction based on several extratherapeutic factors, including the perceived risk to others in society, potential bias against HIV-positive individuals, and possible personal views about the morality of adulterous behavior. Professionalism training for medical students and residents should include the concepts of patient-centeredness, shared decision making, and the role of beneficent persuasion as well as the importance of identifying personal moral biases. Residents and students should learn how to balance their moral values with their professional obligation to their patients while also respecting patients' values and morals. Case vignettes such as those used in our survey can be used in small-group discussions with residents and medical students to help achieve these ends.
The authors would like to thank Dr. Courtney Tibble and Dr. Katherine McFarlane for their assistance in distributing and collecting the surveys.
This study was approved by the institutional review board of the University of California, San Diego.
The opinions expressed in this article are those of the authors alone.
This work was presented as a poster at the Annual Meeting of the Society of General Internal Medicine, Minneapolis, Minnesota, April 30, 2010, and as an oral presentation at the American Academy on Communication in Healthcare Research and Teaching Forum, Scottsdale, Arizona, October 16, 2010.
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