Alejandro Gonzalez
Dr. Emerson
IDMD-101-004
10/10/23

Physicians Being Paid to Prescribe

The article I chose was from CNN Health about physicians being paid by pharmaceutical
companies and how it affected how often they prescribed that drug. The article talks specifically
about opioids and how an overprescription of them could lead to an addiction to the drug which negatively affects the patients well being. They analyzed databases with the information of doctors being paid by companies and compared it to how often they prescribed the drug, in
which they found a positive correlation. A counterpoint was brought up about the doctors truly
believing the benefits of the drug and that the research only proves correlation and not
necessarily causation. Still, there was a large concern about conflicts of interest for the doctor,
and the financial incentive outweighing the best interest of the patient. There are many ethical
questions raised about this scheme, but the two I want to focus on are brought up in Stegenga’s
Care and Cure are medical paternalism and the patient and physician relationship.

Firstly, medical paternalism, which is defined by the NIH as “The physician makes
decisions based on what he or she discerns to be in the patient’s best interests, even for those
patients who could make the decisions for themselves.” This would come into question when the physician prescribing medication was paid a large sum of money by a pharmaceutical company and is now more often prescribing that drug to more patients. It could be inferred that since they are getting kickbacks from those companies, it provides more incentives for the physician to prescribe that medication, to then receive more money. According to the article, pharmaceuticals pay physicians to do research and also for promotional work, they later go on to claim that the largest amount is paid for the latter. The article also goes into detail about a couple of patient cases where the physician prescribed opioids and the effects they had on the patient. Specifically in the case of Angela Cantone, who was prescribed “an opioid called Subsys for abdominal pain from Crohn’s disease”. The drug Subsys was cited as being “50 to 100 times more potent than morphine”, and it caused her to frequently pass out and caused her great discomfort, and whenever she was off the drug it caused “uncontrollable diarrhea and vomiting.” With these terrible symptoms, she consulted the physician who prescribed her the drug in the first place, and he stated that it couldn’t be Subsys causing it. What she responds with is what I want to focus on, which is the fact that she trusted him, “I trusted my doctor as you trust the police officer that’s directing traffic when the light is out.” This is essential to the root problem of paternalism, which is the fact that patients believe they don’t have autonomy when it comes to their health, and in a hospital setting some patients believe that the physician’s word is law. So, when a physician prescribes them medicine, they believe it is in their best interest and that the physician knows best. In even worse cases, like Cantone, when they ask to be switched to a different medication, they simply refuse. There could be a case where the doctor isn’t affected financially, though for this physician it’s pretty clear why, but even then it is a gross offense to the autonomy of the patient, where they can decide for themselves.

In recent times, due to the expansion of media and access to medical information, I believe patients are becoming more autonomous medically speaking, but I also believe that it has
affected the patient and physician relationship. Also called the doctor-patient relationship, it can be defined as, “a consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient.” This involves trust between parties and there is a relationship built, which allows for cooperation and vulnerability. Articles such as this one allow patients to be aware of their voices, but it can also harm the trust of physicians. It is true that the doctors and companies discussed in this article probably had financial gains as a priority over the health of the patient, for which they were sued and investigated. This is to say that not all physicians are like this, the majority will be on the patient’s side and will look out for their best interest. The article stated that “ In 2015, 48% of physicians received some pharmaceutical payment.”, even for those who were, a portion of them were the ones overprescribing medication, though the severity increased as the number of prescriptions increased. So while these cases are immoral, in most cases it won’t end up this way for patients. Though, after people read this article, and others like it, it creates a negative stereotype for physicians, which are greedy people who are self-centered and only care about their gain. This puts a dent in the patient and physician relationship, where the patient has a pre-established notion that the physician is untrustworthy. This is an unrealistic expectation for patients to have against all physicians and can cause a lack of cooperation and trust that leads to other problems, such as misdiagnosing due to their being lack of information divulged.

Overall, I believe that articles being published like this one are helpful to people, it allows them to be aware of problems in the medical field that they might not have known or considered. Always having access to more information is a good thing, it allows people to make decisions for themselves and be more autonomous, which combats medical paternalism. What I have apprehension about is the over-sensationalized of problems presented by the media. While this article I believe showed both sides and provided studies and information to support their claims, not every publication would go through this length. Articles that sensationalize problems and have hyperbolic headlines are often clicked on and sold. This can create a false perspective for people that has a negative effect on the trust between patients and physicians.

Works Cited
Chipidza, Fallon E, et al. “Impact of the Doctor-Patient Relationship.” The Primary
CareKessler, Aaron, et al. “CNN Exclusive: The More Opioids Doctors Prescribe,
the More Money They Make.” CNN, Cable News Network, 12 Mar. 2018,
www.cnn.com/2018/03/11/health/prescription-opioid-payments-eprise/index.html.
Kilbride, Madison K, and Steven Joffe. “The New Age of Patient Autonomy: Implications
for the Patient-Physician Relationship.” JAMA, U.S. National Library of Medicine,
20 Nov. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC6988779/.
Murgic, Lucija, et al. “Paternalism and Autonomy: Views of Patients and Providers in a
Transitional (Post-Communist) Country.” BMC Medical Ethics, U.S. National
Library of Medicine, 29 Sept. 2015,
www.ncbi.nlm.nih.gov/pmc/articles/PMC4589086/.
Stegenga, Jacob. Care and Cure an Introduction to Philosophy of Medicine. The University
of Chicago Press, 2018.

Alejandro Gonzalez
9/5/23
IDMD 101: Medical Foundations I
Presentation Assignment
This week’s topic is about consent, and for today’s readings specifically about informed
consent and autonomy.
The first article from Faden and Beauchamp discusses what is informed consent and
breaks it up into two different “senses”. Sense1 is about informed consent being an autonomous
decision where the patient’s role in making decisions about their healthcare is emphasized and
they actively authorize a proposal or medical procedure. Sense2 is more of an institutionally or
legally effective route of authorization. The focus here is on rules and requirements needing to be
met that were set up by institutions. So, it’s not just an autonomous decision but also a need for
compliance with established procedures. It then goes on to discuss the challenges of balancing
the ethical principles of patient autonomy with established rules. In the end, I believe that Faden
and Beauchamp have more of a favor to sense1, stating that it is the true meaning of informed
consent and that the shared decision-making, which involves a legal definition that aligns more
with sense2, is confusing and rather ineffective.
The second article from Millum and Bromwich also talks about the ethical considerations that
need to be made about informed consent, but this is more focused on the topic of medical
research. For them, it breaks down into two different requirements. One is a disclosure
requirement, where the researcher must disclose all information that is relevant to the participant
and what the participant would reasonably be expected to be told. The second is an
understanding requirement which is that the participant should know that they are being asked
for consent, how to exercise their right to give or refuse consent, and what they are giving
permission for. What the authors emphasize though is that the main function of informed consent
is to make sure the consent is valid and there is a promotion of good communication and
decision making. There were cases presented where patients really didn’t know the full extent of
the research, but that consent was still valid if patients understood the key elements. This then
leads to the importance of effective communication which the article mentions current practices
involving obtaining consent, such as lengthy and complex forms, does not promote that. Rather
agree with and welcome some recent changes in regulations that utilize concise presentations
that give the key information to patients.
So, we can see how both articles discuss the concept and ethics behind informed consent,
though the first article focuses more on medical procedures while the second article is about
medical research.
Discussion questions:
1. How do you define “informed consent”?
2. What is the balance between patient and rules? Whose rights should take precedence?
3. How much should a patient know/ be aware of before consenting?
4. What improvements/changes would you propose to enhance the ethical conduct of
research?
Notes:
• Noah takes an eliminative focus on informed consent, wants each consent form to be
unique to the study and the population group, so you can’t really define informed consent
in one concrete way.
• Some argue for a legal definition of informed consent to protect doctors.
• Without a definition, it leads to inconsistencies and grey areas.
• Consent is needed so doctors don’t take advantage of patients.
• Should have a legal decision, but room for adaptability.
• Adults can consent to whatever they please, but for a minor its different and the doctor
should take control.
• Parents would know best for their children.
• Cannot force anyone to do anything.
• Where should we draw the age of consent in a medical sense?
• What about children in an abusive relation with their parents
• Physicians should report to authorities but should sustain the patient.
• Should be a check list of things being ticked off such as risks/procedures act.
• And allows for patients to ask to follow up questions.
• If the side effects are headaches its less sever then a side effect of kidney failure
• Should make consent forms easier to understand and shorter.
• No pregnant woman wants to enter research trial.
• Consent is more of a humanities problem than a legal one.
Summary of the discussion:
There were a lot of tangents to the main conversation of informed consent, but the summary of
how the discussion ended is as follows. Firstly, that we should have a legal definition for consent
to protect doctors (and hospitals). But the challenge is that we wanted there to be some fluidity
so we can adapt it to different situations. When it came to whose rights should trump all is that
the patient ultimately had free will and autonomy, but it then got complicated when it came to
minors and where we draw the line of the age of consent. Finally, kind of combining the last two
questions, patients should ideally know and understand all essential elements of a research
experiment before consenting, and we can do better by presenting information in an effective and
concise way, and if the participant has any questions or concerns, they should be an environment
where they are able to facilitate this.
Response:
Overall, I was happy with the discussion we had, though a little hectic at sometimes. As always
there are points and flaws to both sides, but I took away that in the end we came to an eventual
agreement on most things. What really came to a point for some people was patient autonomy
and how much emphasis we put onto it. Some believed that the doctor should do what they think
is in the patient’s best interest, even if the patient doesn’t necessarily agree with the procedure,
while others believed we should respect people’s decisions. I didn’t expect for some people to
believe that there was no need for us to define consent or the fact that we should just experiment
wildly on animals, and the conversation also took a turn to vaccines which I want entirely
expecting either. Finally, the crux problem of informed consent is how much should the patient
understand and how much should the researcher disclose. The one point that really clicked with
me was the line “could impair kidney function”, and the fact that people might not even know
how their kidneys function. So, the problem is that even if we disclose information, how specific
should we get, which could lead to making forms longer and more complex. I believe a solution
is to create a safe and trusting environment so that when a participant receives a form, that is
concise and shorter, they can freely ask questions so that they can fully understand the aspects of
the research.