to the editor: I was appalled by the advice given by Dr. Robert L. Dickman in the recent “Curbside Consultation” column entitled “Bending the Rules to Get a Medication.”¹ In the case scenario presented, a young woman with asthma asked her physician to put her mother's name on her prescription because her mother had insurance that would cover the cost of the medication. Dr. Dickman stated that extensive patient advocacy and “consideration for greatest overall utility would win the day over truth-telling.”¹ He further stated that he would take his chances as “this would not even be a blip on the insurance company's radar screen.”¹

I certainly acknowledge that medication costs can be a major barrier to proper treatment. However, Dr. Dickman's advice is not only inappropriate, it is illegal. According to federal law, prescriptions can be written only for the patient for whom it is intended. To write another person's name on a prescription in order for another party's insurance company to pay for that medication is also fraudulent. If physicians wish to pay for a patient's medicine out of their own pocket, then that is their prerogative. However, to fraudulently write a prescription so that an insurance company will pay for a medication for an uninsured patient constitutes theft—it is no different than stealing cash from a local grocery store to pay for this patient's medication. This advice is totally inappropriate for publication in a professional journal.

I recommend that the physician in question consider other legitimate means of obtaining this patient's prescription medication. Public assistance programs, local benevolent funds that are often run by local churches, pharmaceutical manufacturing indigent care programs and other similar means should be considered. Despite Dr. Dickman's recommendation, I believe that honesty in our society really does matter. It is the responsibility of physicians to uphold those standards and use legitimate, honest means of providing the health care that the people in our country need.

to the editor: I was rather surprised at the response that Dr. Dickman gave in the “Curbside Consultation” column on obtaining medication for an asthma patient.¹ Basically, Dr. Dickman advocates that, in certain situations, it is justified for physicians to lie in order to “help” their patients. What Dr. Dickman proposes favors the utilitarian model of ethical thinking, therefore allowing the physician to lie in order to uphold the “greater good,” which in this case is service to the individual patient.

Dr. Dickman spent a great deal of time explaining the moral dilemma that faced the physician—that is, the decision about whether to write a prescription for an asthma medication for this patient using the patient's mother's name on the prescription so that the mother's insurance company would pay for the medicine. His reasoning was that the insurance company made a generous profit and would never miss the few dollars to pay for the medicine. What Dr. Dickman failed to do is to contemplate the ramifications to himself as a physician, to his physician-patient relationship, to the insurance company and to the profession of medicine as a whole.

Yes, insurance companies make money, but they also go out of business. If every physician looked for loopholes in order to give insurance companies' funds to ineligible patients, the number of insurance companies going out of business would increase, higher premiums would result and more people would show up at physicians' offices looking for handouts. Because the perception of income is relative, he could have viewed the situation from the eyes of the patient; physicians make much more money than most of their patients, so why shouldn't the physician be expected to pay for the patient's prescription?

Malpractice lawsuits are often fostered by the perception of the deep pockets of physicians and insurance companies, but also by the impression that some physicians are unscrupulous. By having a physician agree to lie, cheat and steal for a patient, we are reinforcing the image that physicians sometimes cannot be trusted. This cannot help our profession or our patients.

On a personal level, once the patient has seen that the physician is willing to bend the rules for what may be interpreted as a good cause, the patient may begin to find other “good causes” to bend the rules. People talk about their physicians to their friends, so it would not take long for word to spread that the physician in question who wrote a fraudulent prescription is an easy mark. One day it may be asthma medicine, the next it could be narcotics. This not only complicates the physician's practice, but ruins the physician-patient relationship with any patient who presents with an agenda to manipulate the physician.

Dr. Dickman was right in saying that more information was needed. Such information might include whether the patient had ways of changing her lifestyle to accommodate her medicine's cost. For example, does she smoke? Does she pay for cable television? How about a cell phone or a pager? Is she making car payments rather than using public transportation? Does she eat out at all? Does she drink alcohol? Is she living in a house or an apartment that is too expensive? Does she buy new clothes or depend on thrift stores? This is not to imply that if the patient had no areas in her life where she could economize that it would be acceptable to falsify a prescription. It is to point out that what many people consider “essentials” in their lives are luxuries that should be exchanged for necessities—such as needed medicines.

While no one is perfect, and I am sure physicians give in to such moral dilemmas from time to time, it was irresponsible for your otherwise fine journal to allow an unchallenged opinion in it which so blatantly violates what is considered common sense and tradition, not to mention the law.

to the editor: I read Dr. Robert L. Dickman's comments on “Bending the Rules to Get a Medication”¹ with great interest. I believe he provided a thoughtful analysis on the ethical dilemma of how to care for a patient without health insurance who requires medication. His conclusion was, however, illegal.

Writing a false prescription in the name of another insured person is fraud against the insurance company. Often in fine but uppercase print, most preprinted prescription labels include the words:

“CAUTION: FEDERAL LAW PROHIBITS TRANSFER OF THIS DRUG TO ANY PERSON OTHER THAN PATIENT FOR WHOM PRESCRIBED.”

In California, the Business and Professions Code states that “no prescriber shall direct that a prescription be labeled with any information that is false or misleading” [B & P Code, Chapter 9, Division 2, Article 4 § 4078 (a) (2)].

I propose another solution. Instead of writing a false or misleading prescription (however well intended), why not correctly write the prescription, send the patient to your local pharmacy, and charge the cost of the medicine to you—the physician. This would obviate the “chances that this [fraudulent prescription] would not even be a blip on the insurance company's radar screen,”¹ it would not commit fraud against the insurance company and it would provide the patient with her much-needed medication.

This solution too would allow you to sleep well that night—knowing that neither the police nor the Medical Board will come knocking at your door.

to the editor: I am writing in response to the “Curbside Consultation” column¹ in which Dr. Dickman admits that he would agree to write an asthma medicine prescription in the name of the patient's mother. I am distressed by this advice and would like to respectfully offer another perspective and suggest some solutions that have worked in my practice.

It is my opinion that the integrity of the physician-patient relationship is fundamental to maintain as a cornerstone of the concepts of trust and dignity. If I would lie “for” a patient, might I lie “to” or “about” a patient? Is writing another person's name on the prescription really much different than altering a medical record? Is one of these more acceptable than the other? I think not.

I have successfully used the following alternatives in cases in which patients state that they cannot buy even the generic form of a needed medicine:

• Some of my fellow physicians have acknowledged that, although we are business competitors, we are united in the effort for health and have informally agreed to share our resources. We share our pharmaceutical samples with each other's patients in cases thought to be critical.

• One community I serve has an ecumenical ministry group that has established a safety net for food, shelter and medicine emergencies. While they can't fund several medicines per patient on a repeat basis, they have been quite helpful as a stop-gap measure.

• In one community, I had a loan fund tab with the local pharmacy. In a critical case where no other timely alternatives were available, I had the pharmacist put the cost of a small supply of the medicine on my office tab, worked on accessing other more long-term resources for the future and explained to the patient that this fund's availability depended on replacement from its users. The patient is asked to start bringing $1 to $2 per paycheck to the pharmacy on an honor system until the cost of the medicine has been repaid. This worked variably well; some patients were more responsible than others in paying back what they had received.

• For patients with more long-term needs, my nurse maintains a file of assistance programs associated with the pharmaceutical firms. We also try to tactfully conduct some lifestyle counseling for patients who seem to be chronically short of money for medicine. I will discuss the financial benefits of smoking cessation to use the money in more health-enhancing ways. For families I know who frequently dine at the pizza parlor with the whole family for a tab of $20 to $30, I discuss the health and financial benefits of a crock pot of vegetable stew or lentil soup instead of pizza.

I hope these ideas will prompt some brainstorming to seek additional ethical responses to this dilemma.

in reply: It was not the purpose of my remarks in the “Curbside Consultation” column¹ to advocate that anyone should routinely or cavalierly commit fraud. Rather, I wished to stimulate debate and stir the embers on a subject that we will all need to confront sooner or later. Much as we discuss a variety of ethical dilemmas, I understand this one to be an “either/or” choice (a patient in respiratory distress or fraudulent behavior). To suggest any of the variety of “reasonable” alternatives put forth by our correspondents would beg the question and suggest that these hard choices will never have to be made. While truth telling as an absolute value is a noble aspiration, to think that there are never competing values in certain specific situations is naïve.

Indeed, a recent article² reported that 39 percent of physicians admitted exaggerating the severity of their patient's problem, changing the billing diagnosis or reporting signs and symptoms the patient did not have in an effort to obtain insurance coverage for their patients. While writing a prescription on another patient's insurance may be a bit more extreme, it seems clear that fraudulent, illegal behavior is clearly defined by most insurance companies and that changing the billing diagnosis would meet the definition.

Similarly, in an article entitled, “Lying for Patients,”³ that appeared in the Archives of Internal Medicine, the authors showed that physicians were willing to use deception in a variety of cases—57 percent for coronary bypass grafting and 35 percent to obtain screening mammography for their patients. The authors concluded that, “such deception may reflect a tension between the traditional ethic of patient advocacy and the new ethic of cost control.” Dr. Johnson is correct, honesty in our society does matter, but it is wrong to think that under no circumstances are there any competing values that might merit our consideration. Dr. Goddard's argument that today's asthma medication could be tomorrow's narcotic script fails to see that every choice—with its competing values—must be carefully weighed and may be radically different.

My real reason, however, for being purposely controversial was to highlight the extraordinary inequities in our American health care system that would even allow for this case to be constructed! I find these inequities morally offensive and believe strongly that we need to muster at least as much outrage about this as we do about lying for a patient. Ironically, just this week, an article in Newsweek, “The Real Drug War”⁴ features stories about senior citizens whose drug bills outstripped their social security check, or who traveled to Canada or skipped meals to pay for medications. If we physicians, particularly those of us in the family medicine community, believe ourselves to be advocates for our patients (which will include those under or unequally served), we need to confront these inequities head-on. Gaming insurance companies is not the way to solve our health care crisis. Unless we are willing to advocate for justice and fairness in the health care system, I'm afraid that painful “either/or” choices like the “hypothetical” one presented to me will be an ever-increasing reality.

editor's note: This interchange highlights the challenges physicians face in caring for uninsured and underinsured patients. However, I'd like to point out that, in accordance with our editorial policy, the views expressed in the “Curbside Consultation” commentary do not reflect the views of the American Academy of Family Physicians (AAFP). Specifically, AAFP does not advocate falsifying prescriptions or medical records, nor engaging in any activity that might be construed as fraudulent. In retrospect, we should have pointed this out in the original “Curbside Consultation” piece. Admittedly, if AFP's editors and Dr. Dickman had had the benefit of some of these comments during the review process, we undoubtedly would have published a different piece. Be that as it may, we hope that this debate helped stimulate creative solutions to the problems that the “Curbside Consultation” column illustrated.