Carolyn, "trick question?", not really. All doctors, especially those in private practice, have a potential conflict of interest to continue to have that person as his or her patient both from a emotional and financial point of view. Sometimes this conflict between holding onto a patient and yet still providing the patient an opportunity for further or better treatment is part of the professional requirement of putting the patient's best interest ahead of any self-interest. On the other hand, there might be debate as to what exactly is in the patient's "best interest". For example, being a subject (and notice I didn't write "patient") in a research study may not really be in the patient's best interest. Why? The subject may be, by chance, "subjected" to an experimental medication whose value and complete safety has not be as yet fully confirmed and since the study is usually "double blind", neither the researcher nor patient knows which drug or placebo is being administered to the patient. So this is an experiment and NOT a treatment and that is why the patient who is in such a study is a "subject" and NOT a patient. So there can be a very strong argument that the patient's participation in the study although possibly in the interest of all those patients with the disease who await the results of the trial might not be strictly in this patient's best interest. So there you are. participation by a patient is a mark of the patient's altruism and not a clear road to benefit or recovery.

Eric, you have made a reasonable argument in favor of referral, though I am not sure how much a patient can be fully informed regarding the risks vs benefits of a clinical stage 2 (small scale, double blind after grossly apparent toxicity has been found to be unlikely in stage 1 volunteer open testing). That is because I wonder how the referring physician would also be fully aware of risks vs benefits. Irrespective of the physician's desire to keep the patient, should the physician be professionally required at all times to present to the patient every possible option for treatment or should the options be limited by the physician's professional judgment? ..Maurice.

Carolyn, what I was trying to express is 1) Attempting to "hold on" to one's patient could be read as a sign of "self-interest". 2) Providing the patient an opportunity to improve therapy is part of considering the "best interest" of the patient. Generally, as you agree, the patient's best interests should trump the physician's self-interest. I agree too. The ethical question is, however, does enrolling a patient into an experiment also lead to a result which could be read as "best interest for the patient"? Some may argue not for the reasons I detailed above. For example, consider that the situation was that both doctors were neurologists but the other doctor, Dr. S, had perfected an established electro-physiologic technique which was proven safe and effective for those who did not respond to the available drugs for epilepsy. Supposing, to treat the patient with this technique required specific skills that Dr. S. had but the patient's Dr. R. did not have. For Dr. R. to deny his patient the treatment skills of Dr. S. because Dr. R. wouldn't want to permanently lose the patient to Dr. S. to me would be unethical because it put Dr. R's self-interest over that of the best interest of the patient. I hope you see the contrast in this second scenario as compared with my first one where the patient could be referred into an experimental research process where neither safety nor benefit could be promised. ..Maurice.

Eric, I must say that not only the patient's physician is unaware of all the risks and is unaware of whether the drug is beneficial but the same should apply to the researcher. After all, clinical studies to develop new and potent medications require statistical control to establish proof. Virtually all controlled studies require at least two "arms" of the study (unknown drug vs known drug or unknown drug vs placebo) and that at the outset that the experiment the assumption by the researcher should be that there is equipoise. Equipoise means that the investigator must assume for statistical analysis that one arm is no better and no worse in its beneficial effect than the other arm. That is,.the unknown drug is no better and no worse than the known drug or even a placebo (a chemical which is thought to have no therapeutic benefit). Have patients who are considering entering a study understand that such studies are to determine benefit or greater benefit and the assumption on entry is that there is no greater benefit, if any? And even the risks of the unknown drug are not fully known?

There is great demand for subjects in clinical studies but there is inadequate education and detailing of what the subject should understand and expect on signing the consent forms given to them. Even if the studies have been approved by the Food and Drug Administration and the plans reviewed by legally established review boards, bad thing have happened as examples noted in this
article "Major Gaps in Oversight of Human Medical Research" http://www.huffingtonpost.com/2009/10/28/major-gaps-in-oversight-o_n_337399.html

What I am getting at with all these words is despite the fact that yes it is the professional duty to look to the best interest of the patient. Yes, it is a professional duty to inform the patient of all options which could provide benefit with limited risk to the patient. Yes, patient interest trumps self-interest of the physician. Yes, human medical research and development of treatment, at present, can't be accomplished without human subjects. Nevertheless, the physician should not assume that informing and then introducing a patient to a research study is always an ethical good, particularly if the patient is not near death from a terminal disease (where there might not be anything to lose unless the study prolongs the death with more symptoms!). Anyway, that is my opinion. ..Maurice.