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 in their bodies whichof course is dirty in itself but penicillin seems to

    work well for that, these slime-bacteria. Then again

    here in the countryside where one knows that there

    is at least clean soil, clean soil bacteria, [] otherpeople, lets say here from the local meat industry or

    something someone falls on to the floor, and opensa wound, [] then I go over to Staphylococcusmedicines F

    A GP who stated that, at the beginning of their

    careers, doctors always wanted to have culture,

    thought that now he perhaps ought to require

    culture a bit more often than he did, implying that

    his behaviour might be somewhat substandard.

    1. Access to technology: Information from tests

    was considered a waste of resources unless it could

    be used in decision making regarding treatment.

    Laboratory access ranged from full access during

    all working hours to a distance of 200 km or more

    to the nearest laboratory. A GP who had full

    laboratory access always used cultures on slightest

    doubt, whereas GPs with poor access did not

    always send cultures when in doubt. Decreases in

    laboratory access, resulting from cuts in the health

    care budget were described.

    Some GPs omitted cultures because of generally

    receiving results too late for use in treatment

    decisions and some started treatment before results

    were known.

    2. Uncertainty: Many GPs described it as charac-

    teristic for general practice, as opposed to hospitals,

    that 100% certainty of a diagnosis practically did not

    exist. Doubt regarding own competence could cause

    uncertainty. Uncertainty could also occur because of

    gaps in existing knowledge:

    one sees something that one does not find [typical],

    then one takes [culture], then Streptococcus is

    cultivated. How on earth is one supposed to know

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

    434 I. Bjornsdottir and E. H. Hansen

  • whether it is the Streptococcus that caused the

    infection? I dont have any method for judgingwhich of the patients are carriers and have viral

    infections J

    Our informants considered diagnoses to vary in

    certainty, but opinions varied regarding which

    diagnoses were the less certain ones. Some GPs had

    experienced discomfort because of uncertainty.

    Communication skills. Some GPs considered it

    important to find the real reason for the patients

    appointment, even by digging into the patients

    subconsciousness, in order to meet their expecta-

    tions or be able to explain adequately why meeting

    expectations was not feasible (be the peoples

    educator).

    Inadequate communication was observed. A

    woman mentioning antibiotics to a GP after des-

    cribing her cough was asked whether she smoked

    at the time. The woman complained that it was

    unfair to be accused of something that she had

    never done. The GP explained that the question

    was for the observers information. A GP asking a

    young female patient with pain in the lower

    abdomen for a urine sample explained to her that

    he was going to check for chlamydia. Afterwards,

    he told the observer that the health care authorities

    had requested GPs to screen for chlamydia, but left

    the patient unaware of the fact that this was part of

    a routine screening programme.

    1. Patient autonomy at the expense of doctor

    autonomy: Most of the doctors gave examples of

    patient pressure and some described how they

    might give in to such a pressure:

    and then it occasionally happens [] that I donthave the time to sit for 20 min, and explain that the

    kid can get well even though he does not take

    antibiotics []. If it doesnt work in the beginning,of course I take CRP, I take a strep-test, the whole

    lot, try to convince them that there is nothing, but

    on rare occasions, one gives up and prescribes when

    people are totally, well determined and they do not

    intend to step outside, until they have gotten

    something G

    On rare occasions our informants felt pressed to be

    more service-oriented than they felt comfortable

    with, mostly due to fear for complaints from

    patients.

    2. Pressure of time: Our informants felt that they

    often lacked time to do everything that is required

    of them, with two exceptions: one who described

    himself as being in the latter half of his career, and

    another (solo practice, sparsely populated rural

    area) who normally did not experience time pres-

    sure.

    A GP mentioned that under pressure of time,

    one quite quickly started omitting investigations

    that would not make any difference. He also

    mentioned that it was difficult to face the fact that

    time pressure affected ones work.

    3. Slaves of the green forms: The GPs salaries

    depended on a contract with the authorities and

    consisted of a mixture of wages and a fee-for-

    service part, which was collected by means of

    green-coloured forms, signed by the patients.

    Some GPs described themselves as slaves of

    the green forms, indicating that they dealt with

    more patients each day than they felt comfortable

    with. Others were more neutral about the green

    forms, and one thought that this mixture of

    wages and fee-for-service was better than an

    income based on wages alone, because, as exam-

    ples had confirmed, wages alone could make the

    doctors work-shy. The doctors did not think that

    the income and fee-for-service composition inter-

    fered in their diagnoses, but as they gave exam-

    ples of lack of time affecting their diagnoses,

    there indeed seemed to be some interference. A

    possible explanation for this discrepancy might

    be that diagnosing infections (the way our

    informants did it) was not time consuming,

    whereas diagnosis according to recommendations

    might be.

    Obligations towards society

    The nature of the patients job could influence

    decision making. Some occupations, for example

    farmers and fishermen, were regarded as needing

    treatment more quickly than others.

    a man who coughs a little [] either during themating or lambing season for the sheep or some-

    thing, and does not at all want to lose a singleday then I would perhaps also prescribepenicillin to him, I

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

    Ethical dilemmas in antibiotic prescribing 435

  • and

    if well there is a substantial economical questioninvolved A man who perhaps might miss a fewfishing days, at sea, or if he did not get a

    prescription [] [It is] quite OK IPeople holding jobs, for which no stand-in was

    available, might need quick service (because the

    GPs perceived that the job needed to be done), as

    opposed to people working in large companies,

    like supermarket chains (where someone else

    would simply do the job). In most of the exam-

    ples where the nature of the patients job was

    considered important, the reason seemed to be

    concern for keeping society going. One GP, who

    considered that farmers needed quick service, did

    not consider it necessary to culture from, or to

    treat old ladies (in the retirement home) with

    suspected UTI, if it was relatively symptom-free.

    A GP in a rural area gave cost and short shelf-life

    as a reason for not using the rapid Streptococcus

    tests, thereby ranking cost to society higher than

    better diagnosis.

    All strategies for keeping antibiotic consump-

    tion at a minimum can be seen as concerns for

    society as a whole. Although our informants

    societal concerns dealt more with keeping the

    trades and industries going, they were neverthe-

    less aware of the need for restricting antibiotic

    consumption:

    every single prescription that is beneficial to the

    individual, is at the same time also a step towards

    breeding multiresistant (bacteria) strains, thatthen cause these same antibiotics to becomeuseless I

    Fraternal obligations

    There were variations in the ranking of obligations

    towards colleagues. A young doctor working as a

    stand-in for another doctor felt that one should

    work in the spirit of the doctor one was substi-

    tuting, even to the extent of deviating from ones

    own ideals. Many GPs complained about lack of

    time to discuss problems with colleagues.

    The colleagues were also criticized, for example,

    for taking cultures without intending to use the

    results or putting on a diagnostic label as an excuse

    for treatment. Some informants implied that other

    doctors did something irrational, but more often a

    neutral description was used, i.e. referring to

    investigations that had shown this.

    The GPs characterized cooperation with other

    health care professionals as anything from excel-

    lent to demanding. The GPs working in the most

    sparsely populated areas, sometimes used nurses

    as their eyes and ears. Nurses could also be gate-

    keepers for the GPs, by taking phone calls if the

    receptionists could not judge on the acuteness of a

    patients complaint. One informant complained

    that nurses always wanted antibiotics, without

    elaborating on his basis for that opinion. He was

    observed to refuse a request for antibiotics from a

    nurse. He also sometimes felt that the receptionists

    were too demanding.

    The GPs experience of pressure from competi-

    tion varied from feeling the need to limit the

    number of patients.

    If people live outside the area and want to keep

    coming here, then [we dont mind] to the extent we

    are able to, but then, for example, people dont get

    house calls J

    to thinking that GPs were too numerous:

    Im into the second half of all this Im not more busy

    than so that it is just adequate and Im not allowed

    to advertise for patients H

    and

    it can just be said quite clearly, we are manyenough, and, if not too many. Thats the heart of the

    matter H

    The solo GPs in the rural areas did not feel pressure

    from competition, but could feel lack of profes-

    sional support, i.e. be very aware of the fact that

    whatever medical problem arose; they had to deal

    with it.

    One GP was highly sceptical of reports from the

    bacteriological department of the University Hos-

    pital about research results showing increased

    resistance. He implied that the doctors there might

    have created the resistance themselves:

    Dr A: and perhaps a slump of what they have

    caused themselves, you seeInterviewer: At the University Hospital, you

    mean?

    Dr A: Yes I dont know it, you see, Idont know where those pneumococci have come

    from A

    Nevertheless, he sent cultures to the bacteriological

    department, because of good connections.

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

    436 I. Bjornsdottir and E. H. Hansen

  • DISCUSSION

    Two patterns of studying consultations, the

    explorative and the normative, have been identi-

    fied. The normative one might tend to take over,

    when quality assurance becomes the major issue.

    The consequences of that might be counteraction of

    curiosity and thus limitations in the scope of

    research (29). Our research might best be described

    as explorative.

    Rudnick suggests that the autonomy of the

    patient may be breached, for his own good, for the

    good of the public, or for the good of the patients

    immediate environment (30), thereby acknowled-

    ging the possible dilemmas in prioritizing auton-

    omy, beneficence, non-maleficence and justice.

    Disharmony regarding management of infec-

    tions seems mainly to arise through different

    interpretations of how the principles of benefi-

    cence non-maleficence ought to be put into prac-tice. The interpretation of our informants results in

    concern for the person as a social being in a broad

    sense, while the rational clinic paradigm is con-

    cerned with beneficence in the narrow sense of

    health care. The prioritization made by Icelandic

    GPs may or may not apply to other settings, drug

    groups or situations.

    Our informants occasionally gave-in to patient

    pressure. Pellegrino states that both doctors and

    patients are worthy of respect as persons and each

    have prima facie claim to respect for their autonomy

    (31). Patient pressure may on rare occasions violate

    physician autonomy.

    Icelandic GPs resources are in many respects

    limited, as has been confirmed by other researchers

    (32). Other researchers have also found that lack of

    time might contribute to substandard performance,

    as might concern for the doctorpatient relation-

    ship, which seems to be a common reason for dis-

    comfort and worry (1, 33, 34). Uncertainty,

    although rarely disclosed, is also often associated

    with discomfort (1, 35, 36). Physicians tend to cope

    by being biased towards illness (37, 38), i.e.

    emphasize beneficence more than non-maleficence.

    Our results indicate that doctors might emphasize

    more on the eradication of doubt if they do not do

    anything, which is in accordance with Jensens

    findings, that diagnostic work is often more thor-

    ough for patients who are not prescribed medicines

    (39). Using time on dealing with psychosocial

    issues may, at least in the case of antibiotics,

    improve prescribing (40).

    When confusion about prioritizing occurs, dis-

    comfort arises. However, if the GP does not feel

    confused about prioritizing, he does not experience

    discomfort, although his decisions may neither be

    in accordance with scientific rationales nor the

    rules regarding ethical dilemmas. The lack of

    abilities to fulfil the perceived obligations is fre-

    quently caused by lack of resources, but the order

    of prioritization adhered to by the individual doc-

    tor, when working out his practice, is mainly a

    consequence of experience.

    Other researchers have found that gaining

    experience, and pearls (words of wisdom from

    more experienced colleagues), was more important

    to medical students than learning from books (41).

    This agrees quite well with our informants ranking

    of sources of knowledge, but deviates from the

    practice of evidence-based medicine (42).

    A Dutch GP and researcher has argued that

    physicians may integrate societal arguments into

    their practice in a morally acceptable way (take on

    a gate-keeper role), but in order to do so, they need

    resources such as specific information (e.g. about

    prices), diagnostic machinery, guidelines and time,

    in addition to training to perform the balancing

    act (9). Others have argued that it might be

    unethical not to consider costs (43).

    Freidson describes how doctors ignore incom-

    petent colleagues without criticizing them openly

    and argues that the reason is their fraternal

    socialization (37).

    Irrational use of antibiotics poses a threat to

    humankind, even to animals. The balance between

    ecological considerations and concern for individ-

    uals, when antibiotics are prescribed is therefore an

    important, yet difficult dilemma. In order for rules

    and guidelines regarding infection diagnosis and

    antibiotic prescribing to be successful, practising

    doctors real decision making must be taken into

    account. Decisions that might be judged as

    irrational or non-prudent, according to evi-

    dence-based medicine, can seem rational to the

    GPs. Our research indicates that this might be the

    case because both the scientific and ethical guide-

    lines tend to be general, whereas GPs decision

    making is patient-specific and case-specific. In

    another study, GPs most commonly considered

    themselves to depart from evidence-based practice

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

    Ethical dilemmas in antibiotic prescribing 437

  • because of reluctance to jeopardize their relation-

    ship with the patient (44). Physicians have

    tended to express extended responsibility for

    patients they have known for a long time (45).

    Donchin warns that growing dependence on

    instrumentation and laboratory reports contributes

    to devaluation of both clinical diagnosis and sub-

    jective knowledge of patients (46). DeVito, in his

    discussion of the concepts of health and disease,

    finds it absolutely necessary to take the patients

    interests into account. He states, there is nothing

    vicious about the bacteria except how we feel

    about the bacteria (47). This may be interpreted to

    mean that there might be acceptable variations in

    balance between the wait-and-see approach and

    the tendency to treat immediately, which agrees

    well with what Icelandic GPs actually do. Veatch

    expresses doubts about the doctor knowing best,

    and warns them about trying too much to benefit

    the patient, thereby emphasizing the need to

    respect patient autonomy (11). Furthermore, he

    points out that in some cases patient benefit might

    have to be sacrificed to fulfil duties to others.

    Rogers finds both the principle of respect for

    autonomy and the principle of beneficence insuf-

    ficient to ground the practice of medicine, and

    argues that reciprocal trust between patients and

    GPs provides the atmosphere in which patients

    interests may best flourish (48). Tsai recommends a

    Confucian approach, which is two-dimensional:

    the autonomous person and the relational

    person, where the relational person promotes the

    welfare of fellow persons (13). The Confucian

    approach might work, but its usefulness depends

    very much on the acceptance of the patients.

    Arnason emphasizes discussions as means of

    solving ethical dilemmas (23).

    CONCLUSION

    Evidence-based prescription of antibiotics needs to

    take justice into account, i.e. the GPs need to think

    of more than just the individual patient when

    prescribing antibiotics, and the prescribers might

    even need to expand the societal thinking to global

    thinking, i.e. every time they prescribe, they need

    to balance the therapeutic benefit for the individual

    patient against the ecological harm for everyone

    living on the globe. Furthermore, they need to keep

    their competence for doing this up-to-date.

    Whether these are unachievable goals remains to

    be answered.

    ACKNOWLEDGEMENTS

    We would like to thank the two medical doctors

    who commented on an earlier version of this

    manuscript and the two sociologists who helped in

    the initial open coding.

    The Nordic Research Academy, the Icelandic

    Science Council, the Icelandic Research Fund for

    Graduate Students, the Pharmaceutical Society of

    Iceland, the NM Pharma Research Fund, the Ice-

    landic Alfred Benzon Prize Fund, the A. P. Mller

    Fund for Icelandic Students at Institutes of Higher

    Education in Copenhagen provided funding.

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