by Amy Reese, PharmD, MA

Tamiflu (oseltamivir) is a neuraminidase inhibitor which decreases the viral spread of Influenza A and B. It was a revolutionary drug when it was approved by the FDA in December 2000 because it was indicated to reduce the duration and severity of both influenza viruses. It was also proven to prevent a patient from being infected with either influenza virus. The only stipulation with the medication was that its efficacy was only shown within the first 48 hours of influenza symptoms. It was not shown to be effective if given after the 48-hour window. Despite this data, urgent care facilities and emergency departments in every location I have practiced as a pharmacist has handed out prescriptions for Tamiflu. Proper antimicrobial stewardship aside, this practice of giving every patient who shows the slightest inkling of influenza symptoms can pose an ethical dilemma. In my role as a pharmacist, I have run into many cases where the cost of Tamiflu might outweigh the benefits of Tamiflu. Due to the time-sensitive nature of the medication, it is sometimes not beneficial to spend the money on Tamiflu. As a pharmacist, I have a responsibility to educate my patients about the risks and benefits of every medication.

I worked in a community pharmacy located in a low-income area of Southern California where the average income for a household is around $35,000 according to the city demographics. This is very low and barely a livable wage for a household in California. During flu season, my pharmacy ran out of oseltamivir, the cheaper, generic version of Tamiflu, but we still had Tamiflu in stock, which is the more expensive brand name drug. This normally occurs during the winter months because the brand name medication is no longer covered by insurance due to a generic version being on the market. The generic medication flies off the shelves daily whereas the brand name is not used.

One day a woman came to my drop-off window with a prescription for Tamiflu. I told her we were out of the generic medication and to take her prescription to another local pharmacy in order to have it filled. I can legally change Tamiflu to the generic drug, unless otherwise specified by the physician. She told me that she had previously checked other local pharmacies and they were out of the medication as well. Unwilling to give up on her, I checked our stock room for more medication, but we only had the brand name medication. I told her the news and attempted to explain to her that it was probably not covered by her insurance. Just in case, she wanted me to check her insurance. I checked and, sure enough, it was not covered. She had Medi-Cal, which is California Medicaid, meaning that she was considered by the state of California to have low-income. She wanted to know the cash price for Tamiflu. For ten capsules (the treatment dosage for the medication), it was around $130. She was willing to pay for it. I inquired about when her flu symptoms started. The symptoms started after the window closed for Tamiflu to be effective (more than two days before this encounter). I tried to explain to the woman that Tamiflu is only truly effective within a certain amount of time after flu symptoms start and she was outside of that window. She still wanted to purchase the medication. Knowing that the medication may not be effective, and it might be a financial burden on her family, I hesitated, but I filled the prescription for her anyway.

The struggle between paternalism and autonomy pervades healthcare even in the community pharmacy setting. In this case, the struggle was between the patient and myself, the pharmacist, and the cause of this struggle was autonomy regarding decision-making capacity. Both parties (the patient and the pharmacist) want the same thing for the patient- the patient to feel better. The patient cares about getting better and is willing to do what it takes to feel better. The pharmacist wants what is best for the patient, but also knows the science behind the medication and the weaknesses of the drug. This leads me to question whether the patient truly has autonomy in this situation because she does not understand how the drug works.

Autonomy requires all the necessary knowledge (within reason) to make an informed decision. This woman likely lacked the detailed knowledge about this drug given that she had a desire for it despite its proven efficacy after 48 hours. I did not want to encroach on her decision to pay for the medication, however, I had a duty to inform her of the risks and benefits of the medication. I have four years of studying medications and understanding pharmacotherapy and pharmacodynamics from pharmacy school; therefore, I have the clinical knowledge to help my patients make informed decisions regarding this medication and I attempted to educate her about Tamiflu because of the high financial stakes of this purchase.

I would have had less qualms about her taking the medication if it was covered by insurance even despite the decreased efficacy. I had to check my own biases and conflicts of interests when dealing with this patient because I knew my pharmacy would make $130 if I allowed her to pay for the medication without my protest. I could have easily encouraged her to buy the medication understanding “white coat syndrome,” but having a sense of her financial situation due to her insurance I knew I had a duty to protect her interests.

I also had to consider the situation from the patient’s perspective and consider any information about the patient’s life that I am not privy to that may encourage her to purchase Tamiflu. Does the patient’s social situation affect decision-making? Is this patient’s decision actually informed due to the nature of her socioeconomic situation? Because she was on Medi-Cal, she could have a low paying job that will not give her time off for being sick. That could have put her in a situation to be willing to do anything to go to work in order to keep her job – even if that means spending $130 on a medication. Under these circumstances, her decision would not have been completely autonomous because they would have been influenced by her unstable financial situation. The ability to make a decision regarding treatment requires decision-making capacity, but decisions can be skewed based on the individual’s situation: financial, severity of illness, etc. I can only speculate about what she faced in her personal life, but it may have affected her autonomy to purchase this medication.

Healthcare decisions must take into account the patient’s current health status and whether the treatment will help them attain their health goals. We must educate our patients about the risks versus the benefits so they can make the best possible informed decision. This level of decision-making and conflict happens even in a community pharmacy. The treatment prescribed might not help patients while costing them an exorbitant amount of money. In this case, the current medication would not have assisted her in achieving her health goals in addition to the financial costs far outweighing the health benefits of the drug. But ultimately, she had the autonomy to decide whether that decision was fully informed.