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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.