Doctor-patient relationship needed to prescribe meds

Toronto health lawyer Elyse Sunshine says Canadian doctors who are co-signing prescriptions for American patients they haven’t seen can be problematic and risky because of the absence of a direct doctor-patient relationship in these arrangements.

“Doctors have to be very careful and appreciate that the consequences of getting involved in one of these arrangements without taking proper steps can be quite significant,” she tells

“There are professional and liability risks for doctors who participate in an arrangement where they are co-signing prescriptions for United States or international patients for the purpose of those patients being able to access medications at Canadian prices. From the professional regulatory side, regulatory bodies have clearly expressed that there should be no prescribing outside of an established doctor-patient relationship (barring some very limited exceptions). From a liability perspective, the danger is that the doctor, because they don’t know these patients, could be providing a medication that’s not indicated or in the best interests of the patient, which could result in a malpractice claim.

“Currently, this type of arrangement is just not viewed as not good patient care.”

Sunshine, partner at Rosen Sunshine LLP, says it’s important to note the difference between telemedicine — where doctors provide medical services remotely to rural areas often by phone or video link — and this Internet-prescribing service that exists so that American patients can access medications at Canadian pharmacies.

“In telemedicine, there is an effort and an intention to establish a doctor-patient relationship whereas the concern around Internet prescribing is that doctors are prescribing medication for people who aren’t their patients,” she says. “They are, in essence, just co-signing someone else’s prescription with no intention of having any ongoing relationship with the patient.”

Sunshine says these are situations where Canadian doctors have had no prior relationship with these patients and are being asked to co-sign prescriptions to allow the patient to obtain medication from this country because it’s cheaper.

She weighs in on the issue after the CBC reported that critics find it unethical and in violation of standards of care that Canadian doctors are co-signing prescriptions for American patients they haven’t seen.

The article explains that Canada’s Internet pharmacies wouldn’t be able to operate legally without the practice of co-signing because prescriptions written by American physicians require a co-signature from a Canadian doctor before a Canadian pharmacist can legally fill them.

Sunshine says the College of Physicians and Surgeons of Ontario sets out a clear expectation that doctors, in order to prescribe any medication, are to establish a relationship with each patient that includes taking a patient's medical history, (ideally) conducting a physical examination of that patient, arriving at a diagnosis, getting consent for the proposed treatment and then handling the follow-up care.

“There must be an established doctor-patient relationship in order to do any prescribing,” she says. “The concern around this kind of Internet model of prescribing arises where this is not what’s happening.”

At least 27 physicians were disciplined in eight provinces between 2003 and 2012 for co-signing foreign prescriptions; disciplinary action included censure, orders to pay costs and in one case the doctor was fined $25,000, says the CBC.

Sunshine says the Canadian Medical Protective Association, which provides coverage to doctors when they are sued, have said they won’t provide assistance to physicians who are involved in legal actions relating to co-signing Internet prescriptions for people for whom they have no recognized doctor-patient relationship.

"I'm surprised this continues to be a problem because doctors have been sent clear messages in the past that co-signing prescriptions in this manner can have serious consequences for the doctors," she says. “Doctors need to be reminded that even good motives or empathy for patients who are struggling to afford medications in other jurisdictions will not be a sufficient defence if they are viewed as prescribing outside of a doctor-patient relationship.”

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