In the second case, a psychiatrist prescribed narcotics to a patient with a history of addiction. The code of medical ethics is clear: A psychiatrist who regularly practices outside his or her area of professional competence should be considered as having acted in an unethical manner.7 So if you wish to prescribe narcotics, you must follow internal medicine’s ethical standards (Box 2).
Responsibility of care
Although the nurse in the first case could be liable for her actions, the psychiatrist who supervised the nurse might also be partially responsible. The law assumes that those who work under a physician’s supervision act as his or her agents. Nurses working for a physician are the physician’s agents, and the physician is responsible for a nurse’s acts. This legal principle is respondeat superior, or “let the master reply.”
Generally, the physician’s lack of knowledge about what the nurse prescribes is not a defense for a malpractice claim. In fact, the law requires that the physician know whether his or her agents meet the profession’s standard of care. In cases where a nurse prescribes an inappropriate medication, the psychiatrist can be charged with negligent supervision—that is, failing to provide to the nurse proper guidance and instruction.
Ethical conduct
Relationships with patients. The second case raises several egregious issues in patient care. Although intimate relationships with patients are prohibited, the fact that these cases still come before licensing boards and courts suggests that physicians are not getting the message. Although the report of this case is vague about what “intimate” means, several points are raised:
- Sexual relationships with current or former patients are not allowed.7 A patient is vulnerable, and the power differential makes it difficult for the patient to resist the therapist’s requests.
- Nonsexual, intimate relationships likely would be seen as a boundary violation, akin to a sexual relationship. In the case presented, the boundary violation is obvious even though the relationship may not have been sexual.
Internal medicine’s ethical standards for prescribing medication
Inappropriate prescribing. There is no justification for a physician seeking drugs from a patient for personal use, as was reported in the second case. Interestingly, one study found that 17.6% of physicians had used opioids in the past year in an unsupervised fashion.10- Establish a patient-physician relationship.
- Perform and document a medical history and physical exam to justify the medication prescribed.
- Medication must be warranted and consistent with the physician’s diagnosis.
- Dosages and prolonged prescriptions need to be within the usual course of medical practice.
- Maintain accurate and complete treatment records.
Source: Snyder L, Leffler C. American College of Physicians ethics manual, 5th ed. Available at: http://www.acponline.org/ethics/ethicman5th.htm. Accessed August 30, 2006.
Medical ethics prohibit this behavior and state that psychiatrists should not:7
- use the unique position afforded by the psychotherapeutic situation to influence the patient in any way that is not directly relevant to treatment goals
- exploit information furnished by patients.
State medical boards have varying procedures in place to handle a physician’s substance abuse.
These programs’ goal is to assist recovery, eliminate risk to the public, and allow the physician to return to work. Clinicians should be aware of such programs in their jurisdictions.
Drug brand names
- Alprazolam • Xanax
- Buspirone • BuSpar
- Diazepam • Valium