MEDICOLEGAL ASPECTS OF PRESCRIBING

The most frequent subject of malpractice litigation in the United States concerns suicide or failure to exercise proper restraint of a patient. In applying the law of negligence to suicide, it has to be shown that the doctor had owed the deceased patient a duty of care, i.e. that the doctor-patient relationship had existed. Furthermore, it has to be shown that the doctor's standard of practice did not conform to an appropriate known standard. The questions which need to be addressed are: was suicide predictable?; was reasonable care provided with necessary precautions implemented?; and was treatment reliably and dependably implemented? With regard to the foreseeability of suicide, major depression is a known actuarial predictor for suicide, but is suicide always predictable in cases of major depression? With respect to providing reasonable care and precautions, the doctor has to decide on the appropriateness of prescribing antidepressants which are lethal in overdose to potentially suicidal patients. The doctor is bound by ethical and legal requirements to obtain from his patient informed consent to treatment, In the case of toxic antidepressants, this would require him to warn the patient that treatment is toxic in overdose. In the case of the suicidal patient, provision of such information might seem to be negligent. Following the case of Rogers vs. Okin (1979) in Massachusetts, patients committed to the Boston State Hospital had a constitutional right to refuse treatment. Later the use of medication was allowed if the risk of violence outweighed the potential harm of the medication to the patient. However, the law clearly expects doctors to take the lead in defining appropriate standards.