MORAL IMPLICATIONS

Press, Volume CXII, Issue 33093, 7 December 1972, Page 21

MORAL IMPLICATIONS

(By

LAWRENCE ALTMAN,

of the "New York Times." through N.Z.P.A.)

Widespread knowledge of the nature of Dr Max Jacobson’s practice of prescribing amphetamines for many people in show business and politics existed among patients, doctors and Government officials in New York and in Washington.

Some of these people, interviewed by the “New York Times” during the last four months, said that they believed that over the years Dr Jacobson had given the stimulant much too freely. Yet no-one seems to have complained through the available channels. Indeed, some doctors and patients said in interviews that they strongly believed that the medical profession should work by the principles of laissez-faire, that no-one not directly involved had any business interfering with the way a doctor practises, and that people should be allowed legally to obtain dangerous, potentially addicting drugs, if they so choose. The different views of Dr Jacobson’s practice point up serious ethical questions concerning problems doctors have grappled with for decades, if not centuries. The questions are particularly pertinent now as the public challenges the traditional paternalism of medicine in which the doctor’s word and deed go unquestioned. As patients become more sophisticated about medicine, they are also becoming more inclined to demand greater involvement in decisions affecting their welfare. Another such factor is that recent research has led to dramatic new therapies that have complicated the practise of medicine. Many of these advances, such as the development of powerful drugs, have in turn created ethical problems so thorny that doctors say patients must join them in seeking solutions. The questions raised by those who practise like Dr Jacobson range widely. They include the following: How much amphetamines can doctors safely prescribe for an individual patient? Should there be stronger guidelines to protect the public’s health from unwarranted prescriptions of dangerous drugs? To what extent should the public know a President’s medical record and who treats him? Such questions also encompass broader concerns of professional ethics and the ability of medicine to police itself' adequately and of Government agencies to meet their responsibilities. Some new drugs and other therapies have become so popular—even before their value could be fully evaluated scientifically — that patients have demanded that doctors use them for unwarranted conditions. Sometimes doctors sue-1 cumb to these demands. Only after extensive use do the) dangers of such therapies) become apparent to the doctors and the patients. In the case of amphetamines, many Americans

regularly took the drug to lose weight, only to discover that such questionable benefits were far outweighed by the hazards of amphetamine dependence and such toxic reactions as changes in mental behaviour. Accordingly, Federal officials recently took the unusual step of restricting prescriptions for amphetamines, thus intruding into an area of medicine that most doctors had considered sacrosanct. Traditionally, a physician’s prescription habits have been the sole responsibilities of the individual doctor.

Since May 1, 1971, physicians have had to keep records, which are subject to government examination, on the amphetamines that they prescribe. Doctors generally consider use of mood-elevating drugs advisable in treating depression, according to Dr Willard Gavlin, president of the Institute of Society, Ethics and the Life Sciences in Hastings, New York, but he added: “It’s one thing to raise a depressed person’s mood to ‘normal.’ It’s another to give drugs to a ‘normal’ person to make his mood reach some optimal level of happiness. That’s no longer a medical, but a moral issue, and it’s questionable whether doctors should make that decision.”

Yet many doctors question the propriety of any physician’s practice of prescribing amphetamines without telling the patient specifically what the injections contained.

The questions are being raised at a time when “medical ethics” is changing from a phrase meaning good manners to concern for social morals. Formal courses on medical ethics do not exist in most medical schools. Young doctors traditionally have learned ethics by observing the behaviour of their older colleagues in relationships with each other and their patients. Now, a few professors — often at the suggestion of medical students, have organised small courses to discuss how to apply the hippocratic oath and other codes that have existed from ancient times to the problems created by modem medicine. The American Medical Association says that its principles of medical ethics are derived from a code that Dr Thomas Percival, the English physician, published in 1803. It was essentially a list of rules of etiquette governing conduct among doctors. Today, the A.M.A. prin-

ciples of medical ethics and rules of the judicial council state that the medical profession “should safeguard the public and itself against physicians deficient in moral character or professional competence,” and “expose, without hesitation, illegal or unethical conduct of fellow members of the profession.” As for procedure, the principles hold in part that “questions of such conduct should be considered first, before proper medical tribunals.” Officials of the New York County Medical Society said that the society was powerless to discipline a member unless patients or doctors formally complained.

Many doctors who said that they believed that Dr Jacobson was possibly using amphetamine prescriptions excessively did nothing to call the matter to the Medical Society’s attention. Although the reasons varied, for the most part they boiled down to the position that doctor’s were free to practise as they saw fit.

Several doctors said that they had tolerated Dr Jacobson’s practise because many of his patients belonged to “the spoiled rich,” knew what they were getting and had a right to get it. Some Manhattan specialists had a closer look than most other physicians at Dr Jacobson’s practice. These doctors included cardiologists and internists who said they took referrals from Dr Jacobson because he lacked hospital affiliations, and psychiatrists who said they treated patients who had developed reactions to amphetamines prescribed by Dr Jacobson. One internist said he ac-

cepted referrals even though he knew Dr Jacobson had “an uncertain reputation.” Apparently, quirks of human nature inhibited the aggrieved patients in Dr Jacobson’s practice from complaining to medical societies for fear of the embarrassment that such actions might bring. Many of Dr Jacobson’s patients said that the doctor boasted of treating President and Mrs Kennedy. Official records show that Dr Jacobson accompanied the President to the summit meeting in Vienna in 1961. Dr Jacobson said that he gave injections to the President to improve his performance there and just before a United Nations speech in New York. However, it is not known whether these injections contained amphetamine.

A President and his family are treated by a staff of physicians from the ranks of the military, who are available on a full time basis. But in addition, the President has the right, like any other American, to choose his own physician. The fact that a physician like Dr Jacobson could treat —without the public’s knowledge —- a Commander-in-Chief who holds the power to use atomic weapons and make decisions that affect the political health of the world raises anew the question of the need for full disclosure of the President’s medical record. Also the fact that some famous people could continually get legally prescribed amphetamines while others are criticised or gaoled for getting similar, equally dangerous drugs illegally raises questions about the need for even tighter regulations.