The ethics of prescribing

In 1990 the UK Department of Health launched the Indicative Prescribing Scheme. This was described in a document called ‘Improving Prescribing’ (Department of Health, 1990). Family Health Services Authorities, as they were then, were to appoint medical and pharmaceutical advisors charged with the task of improving general practitioners’ prescribing. This description of their task presupposes that improvement is possible, which further implies that some prescribing was ‘bad’ and that other prescribing, by contrast, must be ‘good’. What constitutes good prescribing was not defined, but it was taken to be synonymous with the concept of ‘rational prescribing’, an already well– established concept widely used as a basis for judging the quality of prescribing (Bradley, 1991). The use of the term ‘rational prescribing’ as a synonym for good prescribing also implies that good prescribing is a purely technical matter which involves comparing one's prescribing, or proposed prescribing, to a set of criteria. A relatively simple set of criteria proposed by Parish (1973) is widely accepted. He defined rational prescribing as prescribing that is appropriate, effective, safe and economic. Barber (1995) has highlighted the limitation of this oversimplified technical view. The terms ‘safe’ and ‘effective’ he suggests are absolutes that are rarely achievable. Our understanding of what is ‘economic’ has become more sophisticated with the development of the discipline of health economics. The meaning of ‘appropriate’ was always ambiguous and recent restatements of the definition of ‘rational prescribing’ either elaborate the term or omit it altogether. Furthermore, listing the criteria of rational prescribing fails to capture the reality of achieving ‘good’ patient care, which involves a complex balancing of these considerations. Barber suggests that, rather than judging prescribing per se, we ought to investigate what the prescriber was trying to achieve. He suggests the prescriber has four aims, namely:

to maximize effectiveness;

to minimize risk;

to minimize cost;

and to respect the patient's choices.