Ethical dilemmas in antibiotic prescribing: analysis of everyday practice

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  • Ethical dilemmas in antibiotic prescribing: analysisof everyday practice

    I. Bjornsdottir* PhD (Pharm) and E. H. Hansen MSc (Pharm)*CEO, The Pharmaceutical Society of Iceland, Holtaseli 36, IS-109 Reykjav k, Iceland and Professor,Department of Social Pharmacy, Royal Danish School of Pharmacy and Director, FKL-Research Centre forQuality in Medicine Use, Copenhagen, Denmark

    SUMMARY

    Objective: To explore general practitioners

    (GPs) views on their obligations with respect to

    diagnosing infections and prescribing antibiotics.

    Methods: The GPs reflections and prioritization

    were studied by means of interviews and obser-

    vations. We analysed how their prioritization

    complied with an ethical guidance that ranked

    patient autonomy and welfare highest, then

    competence obligations and obligations to soci-

    ety, followed by fraternal obligations.

    Results: Balancing of pros and cons was promin-

    ent in our informants decision making but often

    resulted in decisions that deviated from the ethical

    guidance. The ranking varied much between the

    GPs. The highest priorities in the GPs practice

    were related to the patients everyday life (some-

    times autonomy, sometimes beneficence in a broad

    sense), doctorpatient relationship (communica-

    tion competence), the patients perceived import-

    ance on the job market (society) and relationship

    with colleagues (fraternal). Perceived lack of

    resources and uncertainty with respect to both

    diagnostic and treatment decisions frequently

    influenced decision making.

    Keywords: antibiotics, general practice, Iceland,

    obligations, prioritization, qualitative methods

    INTRODUCTION

    Physicians often experience discomfort regarding

    decisions on antibiotic prescribing, and also when

    internal rules are broken, even when clashes

    between rules make it impossible to comply with

    all of them (1).

    Antibiotics have been classified as therapeutic

    trial drugs, because, although they are supposed to

    be prescribed only on the basis of certain diagnosis

    of bacterial infections, real life circumstances often

    make certainty in diagnosing difficult or imposs-

    ible (25).

    Ethical problems in everyday practice have not

    gained much bioethical attention (6, 7). The big

    issues have been prioritization, end of life decisions

    and recent advances in biotechnology, although

    physicians role and behaviour, gate-keeping in

    health care, usability of guidelines and paternalism

    vs. autonomy have been discussed (814).

    It still remains uncertain whether the teleological

    (main emphasis on the outcome, maximizing hap-

    piness, joy or good), the deontological (main

    emphasis on the means, having virtuous reasons

    for doing the right thing) or one of the varieties of

    other ethical theories is most applicable (15).

    Although the doctorpatient relationship has

    traditionally been structured around the clinical

    model, which has been described as utilitarian,

    outcome or ends is frequently rather unpredictable

    in health care, which can make a relational model

    (deontological in essence) more appropriate in

    many cases (16). In their Principlism Theory,

    Beauchamp and Childress identify beneficence,

    non-maleficence, autonomy and or justice as thefundamentals of health care ethics (17). Physicians

    have been found to act in accordance with benefi-

    cence principles rather through recognition of

    expertise than because of presumed patient

    vulnerability and lack of understanding, and they

    Received 29 August 2002, Accepted 10 October 2002

    Correspondence: Ingunn Bjornsdottir PhD (Pharm.), CEO,

    The Pharmaceutical Society of Iceland, Box 252, IS-172 Seltjar-

    narnes, Iceland. Tel: +354 561 6166; fax: +354 561 6182; e-mail:

    ingunnbj@itn.is

    An earlier version of this paper was a part of the results section

    of a PhD thesis by the first author. It was defended in August

    1999, at the Royal Danish School of Pharmacy, Department of

    Social Pharmacy.

    Journal of Clinical Pharmacy and Therapeutics (2002) 27, 431440

    2002 Blackwell Science Ltd 431

  • have been found to be inconsistent in their attitude

    towards patient autonomy (18, 19). Furthermore,

    when describing experienced ethical dilemmas,

    they seem to use a somewhat broader definition

    than the bioethics literature (added concerns about

    own reputation and doctorpatient relationship to

    the mainstream definition of conflict and choice

    between values, beliefs and options for action) (20).

    We have described Icelandic general practitioners

    (GPs) rationales for prescribing antibiotics earlier

    (21). We found that their primary purpose of pre-

    scribing antibiotics was to help patients to carry on

    with their everyday activities, i.e. outcome-oriented

    or teleological thinking. Lack of resources, or other

    reasons, however, could cause the GPs to deviate

    from evidence-based medicine. The prescribing

    could occasionally be a result of respecting the

    autonomy of the patient at the expense of benefi-

    cence or non-maleficence, i.e. process-oriented,

    deontological thinking, because of lack of time or

    access to technology, or a belief in the patients

    right to decide (21). Codes of ethics in medicine fail

    to deal with the question of resources (22).

    Moral obligations of health care professionals

    can be divided into four groups: primary

    obligations (respect for autonomy, consideration of

    beneficence), preservation maintenance of profes-sional competence (necessary for the ability to

    prioritize when autonomy, beneficence, non-

    maleficence and or justice clash), societal (publichealth, justice) and or fraternal (23).

    OBJECTIVES

    To explore

    GPs views on their obligations with respect toinfections and antibiotics.

    How GPs prioritize when clashes between per-ceived obligations occur.

    MATERIALS AND METHODS

    The study was conducted in Iceland, a relatively

    sparsely populated country, with its roughly

    280 000 inhabitants, approximately 70% of whom

    live in the capital and surroundings, where the

    largest hospitals and most of the specialists are also

    situated. The remaining 30% of the inhabitants live

    mostly in the coastal areas (rural) where GPs are

    the key actors in the health service. Some solo GPs

    cover an area with travel distances of up to 100 km.

    Physicians have mainly specialized in general

    practice in Sweden. Female GPs have been relat-

    ively few, as have contractors.

    Qualitative methods (in-depth interviews and

    observations) were used to grasp the content of the

    GPs considerations and reflections.

    Interviews

    The sample (10 GPs) was purposefully selected to

    reflect existing variations in the GPs age and years

    of professional experience (two 55 years, mean age 48), gender (two females),

    practice organization (eight state-employed, two

    contractors), practice size (two in solo practice,

    eight in group practice), practice location (three

    rural, seven urban) and postgraduate training (six

    specialized in Sweden, one in Canada, three did

    not specialize), as these factors might influence

    prescribing habits (24).

    Informants were added to the sample until

    the data were saturated. Informants and patients

    exposed to observation, gave informed ver-

    bal consent. The study had ethical committee

    approval.

    The interview-guide was aimed at exploring the

    doctors perceived reasons for antibiotic prescri-

    bing. After the first observation, it focused on atti-

    tudes, common infections (symptoms diagnosisand treatment), patient variables (e.g. age and

    gender), recent antibiotic prescriptions and poss-

    ible associated discomfort, pressure from patients,

    resources and co-operation with other health care

    workers. The physicians were encouraged to vol-

    unteer any information they found important.

    Specialists was an issue initiated by the

    observed interviewed physician in more than oneof the first interviews and hence added to the

    interview-guide. The interviews lasted for 45 min

    to 2 h, and were tape-recorded and transcribed in

    full. One informant did not allow tape recording,

    but detailed notes were kept instead.

    Observations

    Three of the GPs were observed for 310 h each

    (rural, urban, solo practice and two different size

    group practices), each one before he was inter-

    viewed, creating a basis for the interview guide

    432 I. Bjornsdottir and E. H. Hansen

    2002 Blackwell Science Ltd, Journal of Clinical Pharmacy and Therapeutics, 27, 431440

  • and subsequent modification of it. Detailed field

    notes were taken and typed shortly after the

    observation. A total of about 60 doctorpatient

    contacts were observed (including telephone con-

    tacts). Antibiotics and or infections were discussedin 15 contacts. Three antibiotic prescriptions were

    issued.

    Our data seemed saturated (25) after approxi-

    mately seven interviews (i.e. interviews eight to 10

    did not seem to add themes or nuances). This early

    saturation might be due to the use of the observa-

    tions in creating the interview guide and, perhaps,

    also because of the data collectors (first authors)

    experience from primary health care (10 years in

    community pharmacies, with daily contact with

    GPs, with whom antibiotic prescribing was

    frequently discussed).

    Data on ethical dilemmas were extracted and

    analysed by open, axial and selective coding

    (grounded theory procedures), but aiming at an

    in-depth understanding of the informants rather

    than developing concepts and theories (25, 26).

    The interviewers possible biases were minimized

    by researcher triangulation (authors, input from

    two sociologists in the open coding). The

    informants offered information about incidents

    they could have handled better (such incidents

    were also observed). Hawthorne effects were

    therefore considered minimal (27). The results

    are the researchers interpretation of the physicians

    attitudes and behaviour (28), but as a validity

    check, the results were shown to two physicians

    with experience from general practice and pre-

    sented at conferences where GPs were among

    the audience. These physicians confirmed the

    analysis.

    RESULTS

    Balancing of scientific and practical considerations

    was prominent in the GPs decision making. Many

    of them described individual guidelines, or rules

    of a thumb that they had developed to work out

    their practices. They considered this development

    of own style acceptable, even preferable. One

    doctor described this as bringing the art into the

    work. Perceived pressure from patients, society

    (e.g. lack of resources) and or other health careprofessionals was interwoven into practically all

    their decision making.

    The inspiration for the order of our presentation of

    the GPs prioritization is the classification of pro-

    fessional obligations, described in the Introduction.

    Primary obligations towards the client

    The GPs tendency to refer to their clients as peo-

    ple rather than patients (emphasizing the person

    rather than the case) was reflected in their decision

    making.

    Respect for autonomy. The GPs generally paid

    regard to patient preferences when deciding on

    diagnostic procedures or treatment, but varying

    from respecting her right to refusal to meeting her

    demands. Co-operation with patients was consid-

    ered important, especially regarding treatment.

    The use of the wait-and-see method depended on

    the patients preferences.

    An easy access to the GP (appointment within a

    few hours) was considered an important patient

    right, although not necessarily justified by health-

    related needs:

    when you let someone diagnose there is of course a

    risk of a wrong diagnosis, but letting you see itdictate your getting to the doctor, whether you get

    wrong treatment or not, of course that is no good,

    you see. One has a right to get to the doctor when

    the need arises A

    It sometimes seemed unclear, whether respect for

    the patients autonomy influenced the GPs deci-

    sions. For example, when they helped patients to

    avoid sick leave, they sometimes did so on the

    basis of beneficence rather than patient request.

    Beneficence non-maleficence. The GPs defined bene-ficence non-maleficence in a broad sense, not justin terms of health. Their arguments for different

    service levels for different patient groups were

    circumstances in the patients life in general, rather

    than specifically their health.

    1. Job: The patients vulnerability on the job market

    was considered during decision making. Children

    were considered to need quick service, because of

    parents limited rights (generally 7 days year) tostay home with ill children. People, who were

    regarded to be at risk of losing their jobs because of

    sick leaves, were also considered to need quick

    service.

    2002 Blackwell Science Ltd, Journal of Clinical Pharmacy and Therapeutics, 27, 431440

    Ethical dilemmas in antibiotic prescribing 433

  • 2. Nuisance: Doctors in the rural area thought they

    ordered fewer to-be-certain investigations than

    colleagues in the large towns, to avoid unnecessary

    hassle for the patient (implying that avoiding has-

    sle might be more important than certainty in

    diagnosing). A doctor working in a rural area felt

    that he had to keep admittance to a hospital low,

    because of the inconvenience inherent in a hospital

    stay, far away from home.

    3. Economy: Some GPs stated that they would

    omit a test if (in their opinion) the patient could not

    really afford it.

    Actually, the price is only 900 kronur (approxi-

    mately 9 US$). But [] if you have three kids in arow, and if you intend to take a swab, then you

    dont take a swab from the whole row, not unless

    you have tried to treat and it doesnt work D

    A GP who used tests, sometimes forgot to bill

    people for them, thereby ranking the unbilled

    individuals economy higher than cost to society.

    Professional competence

    This section deals with background knowledge,

    technical skills and communication skills.

    Background knowledge. Own experience from work

    in hospitals and discussions with older colleagues

    were considered very important sources of

    knowledge, seemingly more important than

    formal education. Hence, varying experience is

    among the causes of variations in decision

    making.

    Technical skills. Technical skills were perceived to

    increase with increasing experience, justifying

    highly individual necessity for evidence, to confirm

    a diagnosis.

    I think this is a very personal style [] what weare taught, really, is that for sinusitis then this

    treatment is needed and so on, sinusitis can be

    diagnosed by this by X-ray and then perhapswhen one gets more confident in the clinic, then

    one can perhaps allow oneself a bit more C

    One doctor described how he had learned to use

    the smell and appearance of a urine sample to

    distinguish between bacteria. He did not elaborate

    on the success of that method as compared with

    tests.

    Educated guesses regarding causative agents in

    adults occurred. For example, urinary tract infec-

    tion (UTI) causing bacteria in elderly women were

    considered likely to be different from those causing

    UTI in younger women, based on the womens

    assumed (lack of) sexual activity. Examples were

    also given based on the educated guess on the

    patients job.

    We are a bit in connection with the basic industries

    here [] this is just a feeling really, but I get manyfishermen who get hooks i...

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