AMA Journal of Ethics^®

Case

It had already been a busy day at the student health center for Dr. Smith when Steve came in. Steve was a 22-year-old senior in the biosciences program at the college where Dr. Smith worked. He had asthma and type 1 diabetes, and had been coming to see Dr. Smith about these problems for as long as he’d been a student. However, Dr. Smith noted as he looked at his schedule, today’s visit was for something else entirely.

“Hi Steve,” Dr. Smith said. “How’s it going?”

“Oh, it’s okay,” Steve replied. “How have you been?”

“I’ve been well, thanks. I haven’t seen you in here lately—your asthma must be behaving itself!”

“It is,” Steve assured him. “And I still have refills on the insulin you gave me at my last visit, so I haven’t had a reason to come in.”

“I’m glad to hear it,” said Dr. Smith. “So why did you come by today?”

“Well,” Steve started, “my grades haven’t been so great lately, and I’m worried that’s going to affect my chances of getting a job after graduation.”

“Alright,” Dr. Smith responded. “Why do you think your grades haven’t been so great lately?”

Steve was vague in his answers—he couldn’t seem to concentrate, wasn’t able to sleep. When Dr. Smith asked what sorts of solutions he had tried, Steve explained that his attempts to drop things from his schedule and get more sleep had failed.

“Hmm,” said Dr. Smith. “How can I help?”

“Honestly,” Steve said, “last week I took some pills from this guy in my dorm—he says truckers sometimes take them to stay awake for long drives—and they worked really well. I was able to stay awake all night and really get a ton of work done. He’s got a bunch, and he says I can just get them from him, but I was wondering if you had anything like that you might prescribe.”

“You’re talking about stimulants, I think. Something like Ritalin?” Dr. Smith asked.

“I guess so,” Steve said. “My friend says he gets them his cousin, and I think his cousin has attention deficit disorder or something like that. I’ve never had a prescription for them before.”

“Hmm,” said Dr. Smith. “Do you know if your friend has told his doctor about these drugs?”

“I don’t know,” Steve replied. “He seems like a pretty healthy guy. I’m not sure he even has a doctor.”

“Well,” Dr. Smith explained, “those drugs can be dangerous, and we don’t like to prescribe them without a diagnosed attention disorder to treat.”

“Oh,” Steve said. “I didn’t know that.”

“So I don’t think I can prescribe you that kind of a drug, and I also want to advise you against taking the ones your friend offers,” Dr. Smith said. “But I also don’t want to leave you without a leg to stand on. Let’s talk about other things you may be able to do to get a handle on all this stress in your life.”

“Okay,” said Steve.

They talked for a while, and Dr. Smith was left with the feeling that he’d helped Steve out. But he felt unsettled about Steve’s friend. It sounded like he was in need of medical attention and might not be getting it. Further, Dr. Smith was concerned that he might be supplying his stimulants to other students besides Steve.

Commentary

The situation Dr. Smith encounters with Steve is, unfortunately, played out in many student health centers across the nation. A 2010 study of nearly 500 college students who were prescribed medications showed that 35 percent had diverted their medications at least once and that sharing rather than selling was the more common means of diversion. Not surprisingly in the academic atmosphere of the university, prescriptions for attention-deficit hyperactivity disorder (ADHD) were the class of drugs most frequently diverted [1, 2].

Dr. Smith has a long-standing and trusting patient-physician relationship with Steve. Steve feels safe and comfortable disclosing to Dr. Smith his struggles with school and his use of stimulant medications. Dr. Smith approaches the disclosure nonjudgmentally, giving Steve advice about the dangers of taking other students’ medications and educating him about the risk of stimulants. At the end of the visit, Dr. Smith feels he has done a good job handling Steve’s situation but remains concerned about the student who diverted the stimulants. Dr. Smith wonders whether he has a professional responsibility not only to the student who diverted his meds but also to the college community he serves.

A practical framework for analyzing ethical dilemmas might help Dr. Smith work through this. There are many readily available models and theories of ethical decision making. Among the most widely used methods is the principlist model of Beauchamp and Childress [3]. Based on four core values—respect for autonomy, beneficence, nonmaleficence, and justice—principlism is an appropriate approach for a pluralistic setting such as a student health center [4]. Dr. Smith should also consider obtaining either informal advice from a respected and wise colleague or a formal ethics consultation to assist him in specifying and balancing the various ethical claims the case presents. Through this moral deliberation, Dr. Smith can translate his laudable and legitimate concern about student welfare into principled actions.

Undoubtedly aware of his professional obligation to respect Steve’s confidentiality, Dr. Smith frames his ethical question in terms of his “responsibility as a university physician” even wondering if he should “investigate” the diversion. Dr. Smith’s unsettled emotional state constitutes a valid ethical intuition that, honored and reflected upon in a structured manner, can provide insights. Most clinicians reading this case would recognize and sympathize with Dr. Smith’s moral distress. The physician has a sense that if he acted he could prevent harm to the student who is diverting medication, to the cousin, and to other students like Steve who are receiving stimulants without consulting a health care professional. Dr. Smith probably also feels he could help the student who is diverting if he could arrange for him to receive “medical attention.” If Dr. Smith proceeded with his ethical analysis only to this point, then the prima facie obligations of nonmaleficence and beneficence would require him to reach out to the friend, either directly or through the conduit of university authorities.

Herein lies the strength of principlism as a mode of ethical analysis—requiring the balancing and specification of the weight and scope of the core principles through the more particularized and circumscribed moral norms or rules of veracity, confidentiality, and fidelity [3]. The narrative underscores that Steve’s friend is not a patient of Dr. Smith’s. It is this lack of a sanctioned patient-physician relationship that creates the ethical conflict. Any well-intentioned attempt on the part of Dr. Smith to contact the friend would breach the fiduciary obligation he has to his current patient: to keep in confidence what Steve has told him. The sensitive and stigmatized nature of substance use—understood simultaneously as a disease and an illicit behavior—has led to especially strict federal confidentiality restrictions to encourage individuals to seek treatment and ensure clinicians are not forced into untenable conflicts of interest [5].

Though Dr. Smith is motivated by beneficence, respect for autonomy must be observed. Steve is an adult of 22, and the Health Insurance Portability and Accountability Act (HIPAA) protects his confidentiality, as do applicable state privacy regulations and student health center policy just as if he were in a private physician’s office or a local hospital. Legally, the clinic is required to provide patients with written documentation informing them of these safeguards, and the assurance that his communications with Dr. Smith were confidential is probably one of the reasons Steve felt so comfortable with him. That policy most likely stipulated the traditional grounds on which Steve’s confidentiality could be breached: chiefly, a credible threat of serious harm to self or others. Steve’s situation obviously does not fall under these lawful exceptions, and any other release of information without Steve’s consent fails to honor his autonomy.

The Family Educational and Rights and Privacy Act (FERPA) that governs educational records does permit university officials and faculty to communicate confidential student information necessary to protect the welfare and safety of the student or the community; this is in essence a public health consideration [6]. The Jed Foundation has published a definitive guide to student mental health law that frames Dr. Smith’s obligations as clinical and professional, not institutional: “without a student’s consent, a clinician is rarely able to discuss information learned as part of the therapeutic relationship with campus administrators or even acknowledge that the student is in treatment” [6].

Is there anything constructive Dr. Smith can do about the serious problem of diversion of prescription medications on college campuses? As a primary care physician, Dr. Smith has already made a positive contribution by working to help Steve find nonpharmacological ways to improve his scholastic performance and manage his stress. Dr. Smith may want to investigate campuswide initiatives to combat diversion through education, counseling, and treatment rather than addressing a single student’s misuse.

Dr. Smith may also consider updating his knowledge of university resources for students struggling with academic difficulties, so he can provide appropriate referrals for other student patients. His experience with Steve could lead Dr. Smith to study the literature regarding students at risk of diverting medications and using illicit prescription drugs [7] and review his current patient panel for students who could benefit from more frequent monitoring or a frank discussion of the dangers of diverting and using prescription medications [8]. Dr. Smith might also meet with other clinic staff and revise informed consent procedures for prescription medications to perhaps include controlled substance agreements if these are not already used.

The scenario ends with Dr. Smith feeling good about his interaction with Steve yet troubled that he could not help Steve’s friend. The appropriate response to his moral distress is to make constructive changes in his practice that have the potential to benefit many students in the future, fulfilling his ethical duty not only to his patient but to the community as well.