Help: Ethical Dilemma in Real Time
A lady walked into my office yesterday (established patient, though not seen since 2003) with the following question for my staff: her gynecologist had prescribed a course of treatment involving daily injections for a period of time. She didn't want to travel the longer distance to his office just for a daily injection and she didn't want to do it herself. Would I be willing to provide her with this service?
My staff immediately assumed she was undergoing fertility treatments, so they were certain (and correct) that I'd be fine with it. However what she pulled out was a sheaf of papers describing daily injections of HCG for 40 days (except when having her period) for weight loss.
At this point I came to the front desk and started looking over her materials. (It was a good thing I did, because one look at this tall slender lady who wanted to lose weight made my staff want to slap her silly.) I asked her a few questions: the prescribing doctor was her regular gynecologist, not a "weight loss specialist" or someone I could mentally label an "altie doc." There was a long document in tiny font that appeared to be some kind of release, probably from the third party company that was supplying the drug for injection.
I've seen some of the gynecologists in my area doing stuff like this recently; tapping the vast market for weight loss services by purchasing products (usually vitamins and/or "nutraceuticals") and services from third-party companies and then re-selling them to their patients, sometimes along with office visit charges for their services. The first time I saw this I actually called the guy up. I'd known him for a long time and was wondering why he'd gotten into this. All I got was a kind of half-assed, "I dunno; it sounded good, it offers the patients a computerized analysis of their needs based on their personalized profile [right; anything using a computer has to be good]; it doesn't seem to be doing any harm, and the patients like it." I was unimpressed (and lowered my opinion of him slightly) but as long as they keep it in their own offices I don't have much say in the matter. But this is different: a patient is asking me to participate in what I believe is fraud by requesting that I give her injections of a medicaly-unindicated substance.
What do I do? She's standing right there. Yes or no?
Here's what I said: Make an appointment to come back and I will teach you how to do it yourself. She agreed and is coming in tomorrow. Afterwards I realized that there is no difference ethically between giving her the injections and teaching her to do them herself, but it gave me time to think and decide what to do when I see her.
Of course I will begin by calculating her BMI (no way it's over 30; possibly as high as 26, but this lady is NOT overweight) and finding out why she wants (or thinks she needs) to lose weight. I can then (try to) address the body image issues, possibly the mood or relationship issues that are the real problem; at least move away from injections of pregnancy hormone. (That's what HCG is, for all you non-medical readers.) Despite my admittedly formidable powers of persuasion, I don't think I'm going to get very far.
I will then try to explain that the treatment is unproven, not recommended by any competent authorizing body, has no plausible scientific mechanism of action, and like any such therapy has the potential for unforeseen harm. At this point she might ask, "Then why did my doctor prescribe it?"
Now there's a can of worms. "Don't badmouth other doctors" is an important rule in private practice for a variety of excellent reasons. Other docs may know more than I do; patients give different histories to different docs resulting in different treatment recommendations; you don't want them badmouthing you when patients give you different histories, and when you know more than other docs. I can't come out and say, "He's trying to tap into the vast market of desperation and gullibility that typifies women's culturally-induced desire to attain an unreasonable body weight." But I can tap dance around "I don't know" til the cows come home. I may convince her, but I don't think I will.
The most likely outcome of this discussion is that she says, "Thanks for your concern, but I trust my gynecologist ["more than you" is the implication] and I still want the shots." What do I do?
Some other things to factor in:
- Money is not an issue. I can charge her for a level 1 (probably even level 2) visit out of pocket every day and she'd likely pay it gladly. I happen to know she is very well-off.
- Assume litigation potential is not an issue. Of course "you never know" but I know the patient, and I have assessed the risk as negligible.
- Refuse to give her the injections, telling her I've thought about it and can't do it in good conscience. Upside: I'm doing the right thing ethically. Downside (potential): she gets pissed and badmouthes me to friends and neighbors. (Patients aren't bound by the "don't badmouth other docs" rule.) Downside (likely): She'll find another way to get the injections, and so will still incur the "harm."
- Agree to give them to her, then reiterate to her at each visit the points that she doesn't need to lose weight, the treatment is unproven, etc. Upside: I may eventually convince her and she'll stop, thus lessening the "harm." Downside: She may eventually get annoyed/pissed enough to stop coming, but will probably find a way to get them somewhere else and may still badmouth me.
- Teach her to self-inject. Upside (marginal): I am not involved on a daily basis. Also: the patient is pleased with my service. Downside: ethically it's equivalent to giving her the injections without the continued discussions.
Her appointment is tomorrow.