The ethics of rational prescribing

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Editor, – The Health Insurance Commission encourages doctors to prescribe rationally and cost-effectively. The golden rule of medicine is to do one's best for the patient. The silver rule is to do so without bankrupting the country. For those who take the silver rule seriously, it is profoundly depressing to prescribe a cheap non-steroidal anti-inflammatory drug and have the patient return with an unfilled prescription and a request for a COX-2 inhibitor because the pharmacist has told the patient that this new (and four times as costly) drug is better and is subsidised by private health funds. Pharmacists are a necessary and welcome safeguard against prescribing error, but this type of occurrence is more than an isolated incident. Is this type of advice to patients a new form of marketing which is neither socially responsive nor ethical?

Max Kamien
Professor and Head
Department of General Practice
University of Western Australia

Warwick Plunkett, Pharmaceutical Society of Australia, comments:

Professor Kamien raises the difficult subject of the dilemma facing both medical practitioners and pharmacists every day of the 'cost' versus 'technology' weighting in best care delivery to the patient. To fulfill both his gold and silver rules in the incident quoted by Professor Kamien, the pharmacist's advice to the patient was probably correct having first ascertained the patient's private health fund status. The patient would receive the newest anti-inflammatory therapy with arguably less adverse effects and at no cost to the public purse.

The possible error committed by the pharmacist was the lack of professional courtesy in not discussing his advice first with the medical practitioner concerned. Of course, sometimes titles can be intimidating. Perhaps, therefore, the real issue demonstrated by this anecdote is that the general standard of inter-professional communication remains poor and should be a priority for both practitioners and their professional organisations to resolve.