Ethical Case Discuusion
(Ethical Problems related with Viagra)

Masashi Shirahama M.D.
Director, MItsuse National health Insurance Clinic
Lecturer, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan

Today I will send you a new problem.
It is not the case. But it is a big problem for Japanese
Physician especially in Cardiology and Emergency
In Japan Viagra (the new drug for impotence) was started
to be on sale from last week.
But it will make severe side effect when the patient
take nitrate (essential drug for ischemic heart disease)
within 24 hours they take Viagra.
But it is very hard for all the emergency doctor to check
the patient taking Viagra.

1) What kind of method is used to understand the side
effect of Viagra?
In japan it depends on the physician. Some patients only
read the users manual the drug company made.
Some physicians of urology  made written contracts
with the patient.
They now making check list which including as follows;
1, The patient is not suffering from ischemic heart disease
2, The patient understand the side effect of Viagra
3, The patient tell their family doctor about taking Viagra
4, The patient tell their Sexual Partner about taking Viagra
5, The patient cannot use nitrate within 24 Hours after taking Viagra
6, The patient take the responsibility for they cannot take nitrate
if they face heart attack.
7, The patient take the responsibility for they face the side effect
if the Patient don't say the Emergency Doctor about taking Viagra.
8, The patient must not buy or give Viagra for other patient.
so on.
Are these kind of check list also used in other countries?

2) Is all the emergency doctor need to check the patient
taking Viagra? I think it is very difficult to check in emergency
What do the doctors do If the patient loose their consciousness?

Yeruham Frank  Leavitt, Ph.D.
Chairman, The Centre for Asian and International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva, Israel

Dear Masashi

Thank you for the interesting information about Viagra and nitrates.
Please accept my apologies for replying so late.  I agree that patients
should definitely not be given prescriptions for drugs unless fully
informed about possible side-effects.  I would add that if a physician
thinks that a drug will harm the patient then he/she has every right to
refuse to prescribe it even if the patient has given informed consent.
All people must act according to conscience. A simple shopkeeper should
refuse to sell an item to a person who would obviously be harmed by it.
And this obviously applies to physicians as well.

(Some people think that physicians have more of an obligation in this
regard than do others, but I think the obligation to act according to
professional knowledge and ethical conscience applies equally to all

But I have a request of you.  Although  I am not a physician I try to keep
up on general medical literature, but I hadn't seen literature  on dangers
in combining Viagra with nitrates.  If you will send me some references to
the medical literature I shall be grateful.

Very best,  Frank

Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic

Dear Frank Leavitt

Thank you very much for your mail.
I think following home page will be useful to get the information of Viagra.

Pfizar Company home page of Viagra

American Heart Association Recommendation

FDA's Recommendation for Viagra

Thomas R. McCormick
Box 357120 UW School of Medicine
Seattle, WA 98195-7120

Masashi and Frank,
I just learned that there was a physician who agreed to work for an
internet organization in Washington State, and when men wrote in via the
internet complaining of impotence, he prescribed Viagra without actually
seeing the patient or doing any tests etc., and now his license is being
suspended by the Wash. State Comission on Licensure for failing to
practice according to community standards----so you see, the problem
continues. . .

Ole Doering
Research Fellow, Institute of Asian Affairs, Hamburg
Cross-cultural Philosophical Hermeneutics
Practical Theory of Science
Medical Ethics

Dear Frank (and other friends on this mail's voyage),
I am happy to read your lines after a while. I, too, can not really engage in
reasonable discussions these months. I am too much involved in so many
research and administrative works, plus preparations for the Shanghai
Symposium, of which, I am sure, you have heard (info update attached below).
Let me just reply that I fundamentally agree with your principle saying that
"the obligation to act according to professional knowledge and ethical
conscience applies equally to all people". I also feel that there is in deed
an imperative to act according to one's professional knowledge, and that this
imperative is part of ethical conscience. However, the intimacy with
existential problems of the body&soul practically urges physicians
particularly to explore their conscience, and provides more occasions for the
necessary involvement of their professional knowledge and conscience. This
makes them more likely in practice to feel obliged.
But shall not each one of us always be well prepared?
Have a good evening, with kindest regards, yours

Yooseock Cheong M.D.
Department of Family Medicine
Dankook University, College of Medicine, Korea

Dear Masashi,
Nearly two months has passed since you sent viagra case to me.
I apologize my replying so late. Actually, at that time, Viagra didn't come into Korea, but, we will allow its prescription within several months. Your question is very
interesting and concerning matters. I totally agree to check list of Japanese urologists. It maybe helpful to Korea. Could you let me know about it in detail? (Your check
list are ended No 8, Is it whole lists?) Anyway, I think education and warning about side effect of Viagra is responsible to physician. So, your check list is very useful.
About your second question, I think there is an answer in your check list No 7,  E very physician in emergency room should ask about taking Viagra to patient especially,
needed take nitrate. But, if patient loose his consciousness, physician is not responsible to prescribe nitrate although side effects happened.
If Japan has any experiences of your concerning side effects or accident, please let me know about it.  Today, I received comments from Frank, McCormic, and Ole. If
you will send me some other comments you have, I shall be thankful.

By the way, I started smoking cessation clinic in my office 3 weeks ago, and it's very interesting to me. How are you doing nowadays?

Stuart Sprague, PhD
Associate Professor of Family Medicine
AnMed Family Practice Center
Anderson, South Carolina  USA

New Ethical Case (related with Viagra)

I am glad that there were others who have responded to the case about Viagra.  I had felt guilty that it had taken me so long to reply.  Now I can send you my comments and add some other issues.

On the Viagra issue, I agree with comments made by others.  There is an ethical obligation not to prescribe any medication without knowledge of the patient's physical condition and without the patient being thoroughly informed of the beneficial and potentially harmful effects of the drug.  Every doctor faces situations where their knowledge of the patient is incomplete and/or the patient's level of information is incomplete.  Inevitably, some prescriptions are made under less than ideal circumstances.  The doctor assumes ultimate responsibility in all cases.  Having a written contract can ensure that the patient has been acquainted with all the issues, but may not always be necessary.  Such a contract is not possible with every prescriptions.  I am not aware of American physicians who require a written contract for Viagra.  This is a drug which seems to be a special case for several reasons, so heightened awareness may be necessary.  Because of its cost and its relationship to sexual issues, economic incentives and the potential for abuse may be greater.

I heard the other day that oral contraceptives have been approved in Japan for the first time.  Is that so?  What are the specific types approved?  I am interested in the question of whether this change after many years of resistance is related to the rapid approval of Viagra and the charge by feminists that it was sexist to approve Viagra and not allow contraceptives for women.  Was that a factor?  If so, what role did it play in the political debate?

Thank you for your patience with me.  I do enjoy our electronic conversations.

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