Aristotle is cited in the journal Palliative Medicine in a 2008 paper investigating "Challenges faced by palliative care physicians when caring for doctors with advanced cancer." The Greek philosopher, say the authors, "would argue that treating doctors like other patients is unethical since 'people can be treated unjustly even if they are treated equally'. It could be argued that doctor-patients are a group that are truly empowered to exercise their autonomy, and this should not be discouraged."
It is a view confirmed by the results of a recent Irish survey of 729 non-consultant hospital doctors, published in the Journal of Medical Ethics, showing the widespread practice of self-prescribing medication for themselves, family and friends: "Two-thirds of respondents had self-prescribed, over 70 per cent had prescribed to family, and nearly 60 per cent had prescribed to a friend or colleague."
Is it illegal for a doctor to self-prescribe for themselves and family/friends?
The study's lead author is Dr Yvonne Hartnett, a psychiatrist-in-training at Dublin's St Patrick's University Hospital. Dr Hartnett told The Irish Times: "It's not illegal. However, the Irish Medical Council's Guide for Professional Conduct and Ethics for Registered Medical Practitioners (2016) states: 'You should not treat or prescribe for yourself" (paragraph 58.1), and 'You should not treat or prescribe for members of your family or others with whom you have a close personal relationship except in emergencies. You must not prescribe controlled substances for them or issue sick certificates or reports for them except in emergencies' (paragraph 60.1).
The phrase ‘should not’, adds Hartnett, “is used for prescribing to yourself or people you know, but the phrase ‘must not . . . except in emergencies’ applies to prescribing addictive substances to family.”
Significantly, Hartnett’s team found that “some 3 per cent to 7 per cent who had self-prescribed had prescribed an opiate, benzodiazepine or psychotropic medication”.
Hartnett speculates that self-prescribing could be influenced by risk factors such as work-life imbalance, lack of control at work, lack of support and intensely busy and under-resourced workplaces: “Absenteeism among doctors is rare and doctors will regularly come to work sick as they don’t want to let down their colleagues. They may self-prescribe an antibiotic to hasten their recovery so they can continue to work, and work commitments might constrain their attempts to see a GP. Ireland’s medical community,” explains Hartnett, “is small, so doctors may worry about their confidentiality being breached if they’re seeing another doctor about mental health or substance use issues.”
A possible role for burnout in self-medication can be inferred from a recent Canadian study of medical students published in Social Psychiatry and Psychiatric Epidemiology which reported that "in addition [to] significant distress, there is the added risk of inappropriate self-care practices such as self-diagnoses and treatment, self-medicating and substance use, which has the potential to lead to substantial impairment."
Such impairment could be problematic, and Hartnett offers an Irish perspective: "Doctors in Ireland are under enormous pressure and often unfairly portrayed in the media. Twenty-four-hour shifts – sometimes longer – are typical and chronic health service underfunding leads to the experience of moral injury by doctors, where the care we believe we should give isn't possible due to resource constraints. For example, as psychiatry trainees we see more people with mental health difficulties in emergency departments that we'd love to admit to hospital and who want to be admitted, but there aren't beds. We're forced to turn these people away and then worry about them."
Hartnett is clear that education is needed for doctors to seek independent medical care: “Doctors have worse health outcomes that the general population, and need to learn how to be patients, and all doctors need to learn how to treat other doctors.”
The Royal College of Physicians of Ireland, commenting on the study said: “The RCPI believe doctors have a responsibility to themselves, their families, their patients and the healthcare system to take care of their own health. We advise doctors to monitor their physical and emotional well-being, and to seek assistance early if they have any concerns or feel they are experiencing significant stress . . . [W]e encourage doctors to provide support and assistance to colleagues in a confidential, sensitive and professional manner. This means reiterating the importance of the GP role, ensuring it is not bypassed and discouraging the casual or ‘corridor consultation’.”
The College of Psychiatrists in Ireland (CPsychI) said that self-care and health sessions/modules are an integral part of its week-long induction course for foundation year basic specialist trainees, including a session from Dr Íde Delargy from the Practitioner Health Programme. And Hartnett is clear that: "Apart from education, increased resourcing of the practitioner health programme is needed. Consideration should be given to expanding this for more than mental health and substance use issues."
The CPsychI also added that professional behaviour is an area which is also likely to come up in Balint groups for trainees. Balint groups – named after the psychoanalyst Michael Balint (1896-1970) – are reflective practice groups guided by an experienced facilitator, and are mandatory, uniquely for psychiatry trainees.
The publication of Dr Hartnett’s report in a medical ethics journal rightly focuses an ethical spotlight on self-prescribing among doctors. But it also helps illuminate the ethics of doctors working in under-resourced, stressful environments, and raises the important question of the extent to which a civilised society is prepared to tolerate the administration of healthcare in such conditions.
