Neil J. Farber, MD, FACPLynette Cederquist, MD

Mary Devereaux, PhDEd Brown, MD

University of California San DiegoLa Jolla, CA

BackgroundThe growing use of medication for the treatment

of erectile dysfunction presents a number of ethical challenges.

Conflicts occur between caring for an individual patient vs. extra-therapeutic factors such as public health concerns, moral concerns, and bias.

No study has examined physician attitudes toward prescribing medication for erectile dysfunction.

PurposeSurvey residents about their willingness to

prescribe sildenafil in ethically challenging scenarios.

Determine if extra-therapeutic factors influence resident decision-making.

Methods• Cross sectional survey• All 128 UCSD IM and FM residents• Pretested among 40 general internal medicine faculty

at UCSD• Survey contained 10 different scenarios for which

students could prescribe sildenafil– 4 point Likert-type scale– 4 variables

• HIV + or HIV -• Homosexual or Heterosexual• Safe sex vs. risky behavior• Adulterous vs. monogamous relationship

• Demographic and attitudinal data

AnalysisDifferences by variable analyzed by t tests

Number of scenarios viewed as very likely or likely to be prescribed by respondent calculated

Association of demographic variables with number of very likely/likely scenarios prescribed analyzed by multiple regression model

Demographics of 81/128 (63%) RespondentsAge 29 +/_ 2.7 years

Gender Male 43 (53%)

Female 37 (46%)

Residency IM 64 (79%)

FM 16 (20%)

Yr of Residency 1st Year 27 (33%)

2nd Year 22 (27%)

3rd Year 31 (38%)

Attitudes of 379 RespondentsAttitude Agree Disagree

Patient Has Priority

59 (73%) 20 (25%)

Low Morals No Rights

8 (10%) 69 (85%)

Protecting Society

49 (60%) 27 (33%)

Protect Pt From Himself

70 (86%) 8 (10%)

Figure 1 % of Respondents Likely to Prescribe Sildenafil Based On Risk

P < 0.001

Figure 2 % of Respondents Likely to Prescribe Sildenafil Based on HIV

P < 0.001

Figure 3 % of Respondents Likely to Prescribe Sildenafil Based On Morality

P < 0.001

Association of Attitudes With Likelihood of Prescribing Sildenafil

Agree Disagree

Patient Priority 6.3 +/- 2.2 6.7 +/- 1.7

Morals No Rights 5.2 +/- 2.6 6.6 +/- 2.0

Protect Society 6.5 +/- 2.1 6.8 +/- 2.1

Paternalism* 6.2 +/- 2.1 8.1 +/- 1.4

*p = 0.005

LimitationsSelf-report about residents’ beliefs and actions

Can only determine attitudes rather than what residents would actually do

Report of prescribing medications not confirmed by other means

Single site for residency programs

ConclusionsMany residents make decisions about

sildenafil prescription based on extra-therapeutic factorsRisk to societyBias toward HIV infected patientsMoral judgments about adulterous behavior

Residents’ attitudes about paternalism affect their prescription of sildenafil

ImplicationsResidency programs should help residents to

find the appropriate balance between:Respecting autonomy and protecting societyOne’s moral commitments and appropriately treating

patientsDealing with one’s biases and caring for patients

The impact of paternalism on resident behavior should be addressed by residency program directors.