Physicians’ dual obligations to serve both the well-being of their individual patients and that of other patients and the community at large come into sharp tension in a pandemic. Physicians must balance competing responsibilities simultaneously, notably in the decisions they make about when and how to draw on resources that are limited and critically needed by all.
When prescribing a drug or device for an individual patient, physicians are expected to base their decision solely on the patient’s medical need (Opinion 9.6.6, “Prescribing and Dispensing Drugs and Devices,” AMA Code of Medical Ethics). Yet at the same time, they are also expected to:
- Participate in activities that contribute to the improvement of the community and the betterment of public health (Principle VII, AMA Principles of Medical Ethics)
- Promote access to care for all (Principle IX)
- Be prudent stewards of societal resources (Opinion 11.1.2, “Stewardship of Health Care Resources”)
- Not knowingly contribute to health care disparities (Opinion 8.5, “Health Care Disparities”)
Extending a prescription from 30 to 90 days for one patient may deprive two others of a medication they equally need and, absent compelling justification, would fall short of balancing these professional ethical obligations.
That doesn’t mean that it might not be possible, under certain conditions, to justify such a decision. Drawing on criteria for allocating limited resources set out in Opinion 11.1.3, “Allocating Limited Health Care Resources” suggests that justifying conditions might include considerations such as the acuity of the individual’s need for the medication in question; the lack of any clinically reasonable alternative; the patient’s uniquely high level of risk for adverse effects if, by day 31, they don’t have access to the medication; and the likelihood of the resource being replenished in the interval. The greater the need of the community, the more stringent the resource limitation and the less likely the risk of a significantly adverse outcome for the individual, the weaker the justification becomes for giving one patient what amounts to privileged access to care.
Allocating limited resources to one’s own family or other intimates in a way that privileges these individuals over others is problematic not only as an issue of access to care, but also as a separate matter of professional ethics. Opinion 1.2.1, “Treating Self or Family,” addresses the challenges posed by treating patients with whom a physician has a familial relationship. At issue are concerns that the relationship will undermine objectivity, patient autonomy and informed consent. Treating a family member may adversely affect the physician’s ability to remain objective and thorough, including the risk of treating beyond their expertise or training. So too, family members may be reluctant to share sensitive information, to openly state that they prefer another physician, or to follow recommendations.
Physicians may ethically treat family members in only very limited circumstances:
- In an emergency (or isolated setting) when no other qualified physician is available – and only until another physician becomes available
- For short-term, minor problems
Additional ethics guidance in a pandemic
The AMA offers an overview of foundational guidance regarding medical ethics for health care professionals and institutions responding to the COVID-19 pandemic.