Title: Ethical Implications of Long-Term Pharmacotherapy: A Principled Analysis of Risk, Benefit, and Chronic Disease Management

For this section you will choose a topic triggered for you, as a result of talking to your patient.

The essay you decide to write should relate to either a psychological issue around illness and

health behaviour, or social factors affecting the patient’s development and experience of

illness. Alternatively, it could be a particular ethical issue of interest to you that is relevant to

the patient in question or could be significant in their future care.

Think about the patient’s health overall – not just the presenting condition. Patients may have

co-morbidities, and the recent episode may be just one incident in a long-term condition.

If you decide to write an essay on ethics, consider what the legal as well as moral arguments

are and how they relate to the care and decisions around management in your patient’s case.

Apply these principles to the investigations, treatment and management that might be

appropriate for the patient’s health problems. Discuss ethical issues which you believe are

(or will be) raised in the treatment and care of your patient. ESSAY

The following is a guide to marking.

Assessors should consider the following areas & score up to a max of 25 marks:

Introduction

Literature review and knowledge

Integration of information

Relevance to the patient

Discussion/Summary/Conclusion

References

These descriptors should act as a guide to marking only Mark

Excellent. Complete command of the relevant concepts and

facts; well researched with an excellent understanding of the

literature with evidence of substantial reading in and around the

subject; a high level of critical and/or analytical thinking; evidence

of using a wide range of sources including the original research

literature. Thoughtful consideration of potential implications for

the patient. Good evidence that all the relevant information has

been integrated into single coherent body of work. Excellent

standard of presentation.

23-25 marks

Good. Clear exposition of the subject. Fairly comprehensive

grasp of the relevant concepts and facts; gives a mainly accurate

account of the relevant literature; shows some evidence of

reading around the subject and shows some critical/analytical

thinking. Considers potential implications for the patient. Well

presented with minimal errors.

18-22

Clear Pass Essay that shows a reasonable grasp of the basic

concepts and facts; gives a mainly accurate account of the

relevant literature. Some reference to the patient. Acceptable

standard of presentation.

14-17

Essay Plan:

Itroduction (Approx. 150–200 words)

• Present the core ethical question: Is it ethically justifiable to continue treatment that may cause long-term harm, even when no better alternative exists?
• Highlight why this issue is relevant in modern medicine (aging population, polypharmacy, multimorbidity).
• End with a thesis statement: The essay will explore ethical principles (autonomy, non-maleficence, beneficence, justice), legal context, implications for patients, and the role of shared decision-making.

What is the ethical problem surrounding long-term drug treatment?

Why is it relevant now (e.g., ageing populations, polypharmacy, multimorbidity)?

What specific patient case will this essay reference?

What is your main argument/thesis?

Literature Review & Knowledge (Approx. 400–500 words)

• Present key evidence around adverse effects of long-term drug treatments:
• Antipsychotics: metabolic syndrome, tardive dyskinesia
• Opioids: dependence, tolerance, overdose
• Corticosteroids: osteoporosis, diabetes
• Summarise major ethical theories (e.g., principlism – Beauchamp & Childress) and how they apply to chronic treatment.
• Review legal standards (e.g., GMC guidance on informed consent, Montgomery v Lanarkshire Health Board 2015).
• Discuss health inequalities in long-term treatment and medication burden.

Point: Long-term pharmacotherapy raises complex ethical tensions between autonomy, beneficence, non-maleficence, and justice.

Evidence: Refer to Beauchamp and Childress’s Four Principles of Biomedical Ethics.

Explanation: Each principle may conflict in cases of chronic medication—e.g., beneficence (suppressing symptoms) vs. non-maleficence (causing long-term harm).

Analysis: Critically explore how these tensions appear in a real patient’s case (e.g., Mr A on antipsychotics or Mrs B on long-term corticosteroids).

Link: Understanding this tension is essential in ethically sound, patient-centred chronic care.

Question: How does informed consent function in long-term drug treatment, and is patient autonomy truly respected over time?

• Point: Long-term treatment often undermines informed consent, particularly when side effects are not fully explained or understood.
• Evidence: Reference Montgomery v Lanarkshire (2015) and GMC guidance on consent.
• Explanation: Autonomy requires ongoing, informed dialogue—not just one-time consent.
• Analysis: Use patient example: did they truly understand the risks (e.g., tardive dyskinesia, osteoporosis, dependency)? How did their understanding evolve over time?
• Link: Respecting autonomy demands more than a signature—it requires continuous ethical engagement.

Question: Is it ethical to continue long-term treatment that causes harm when alternative options are limited?

• Point: Long-term drugs can create harms that are minimised or ignored in favour of stability or convenience.
• Evidence: Cite studies on the harms of antipsychotics, corticosteroids, opioids, PPIs, etc.
• Explanation: Even if symptoms are controlled, cumulative toxicity, dependence, and reduced quality of life can result.
• Analysis: Discuss your patient’s lived experience—are the harms tolerable, or are they ignored because there’s no “better” option?
• Link: Ethical care must continually re-evaluate risk-benefit ratios, not assume “stable” means “safe.”

Integration & Application to Patient Case (Approx. 400–500 words)

• Use the patient’s story to illustrate:
• Physical or psychological burden of treatment
• How adverse effects were (or weren’t) discussed
• Quality of life issues
• How the patient feels about continuing treatment
• Reflect on whether true informed consent occurred.
• Explore alternative management approaches (e.g., deprescribing, non-pharmacological strategies).
• Discuss how their care reflects broader systemic or ethical challenges.

Discussion & Critical Analysis (Approx. 300–350 words)

• Critically weigh up the ethical tensions:
• Autonomy vs. paternalism
• Beneficence vs. non-maleficence
• Individual burden vs. public health priorities
• Consider future care planning: how should the adverse effects be monitored? When does harm outweigh benefit?
• Discuss shared decision-making – ideal vs. reality.
• Optional: Address potential resource limitations or societal values (e.g., cost-effectiveness vs. patient-centred care).

Question: What are the core ethical principles at play in long-term drug treatment, and how do they guide or conflict in practice?

• Point: Long-term pharmacotherapy raises complex ethical tensions between autonomy, beneficence, non-maleficence, and justice.
• Evidence: Refer to Beauchamp and Childress’s Four Principles of Biomedical Ethics.
• Explanation: Each principle may conflict in cases of chronic medication—e.g., beneficence (suppressing symptoms) vs. non-maleficence (causing long-term harm).
• Analysis: Critically explore how these tensions appear in a real patient’s case (e.g., Mr A on antipsychotics or Mrs B on long-term corticosteroids).
• Link: Understanding this tension is essential in ethically sound, patient-centred chronic care.

Question: Do long-term drug regimens reinforce health inequality or unjust burden on certain populations?

• Point: The burden of long-term medication often falls unevenly across socio-economic, ethnic, or age groups.
• Evidence: Refer to studies on health inequalities, multimorbidity, and access to deprescribing or alternatives.
• Explanation: Some patients may lack resources to question care, manage side effects, or advocate for change.
• Analysis: Use patient example: Did their background affect their ability to participate in care planning? Did systemic factors (poverty, mental health, age) limit their options?
• Link: Ethical care demands attention to justice—not just what is possible, but what is fair.

Question: How can shared decision-making improve ethical care in long-term pharmacotherapy?

• Point: Ethical care involves partnership, not passive compliance.
• Evidence: Refer to NICE guidelines and critiques of the “doctor knows best” model.
• Explanation: Patients must be co-owners of their treatment journey.
• Analysis: Reflect on your patient’s experience—were they involved? What changes could empower them (e.g., medication review, better education, alternative therapies)?
• Link: Ethical care in chronic illness is dynamic—patients must be supported, not managed.

Conclusion (Approx. 100–150 words)

• Recap the core argument: Long-term drug treatments require nuanced, ethically grounded decision-making.
• Emphasise the importance of communication, ongoing consent, and personalised care.
• End with a reflection: improving ethical practice requires listening to patients, not just treating disease.

Questions to address:

• What are the key ethical risks of long-term drug treatment?
• What have you shown about autonomy, harm, and justice through your patient case?
• What should change in future care—how can we do better?

Reinforce your thesis: Long-term treatment must be regularly re-evaluated through ethical and patient-centred lenses. Shared decision-making, transparency, and attention to harm are essential to protect both health and dignity.

Written so far:

A Chronic disease is defined “as an ongoing/recurring illness,not caused by infection or spread through contact, that does not resolve spontaneously. And are rarely cured by medication or other medical procedure.”(1) Management of chronic diseases is heavily reliant on key principles such as continuity of care, patient centeredness and shared decision making. (2) These principles are essential to help navigate the complexities of long term pharmacotherapy used for symptomatic treatment rather than curative care. These Long term pharmacotherapies used can result in long term Adverse effects. For instance long term oral corticosteroid (OCS) used in Asthma and COPD can result in Cushing’s disease,increased cardiovascular disease risk & Osteoporosis. Atypical antipsychotics used in schizophrenia and Bipolar disorder can cause serious metabolic conditions- weight gain,Type 2 diabetes and insulin resistance- if used long term. While these treatments help control these conditions and improve patient quality of life, they come at an increased risk of Adverse effects with long term use.This raises an interesting Ethical dilemma of whether these adverse effects risk is outweighed by the benefits. Is it justifiable to continue treatments in the long term if they may cause significant harm? Especially if no other treatment alternatives exist? As patients are living longer with chronic diseases, the accumulating risk of adverse effects, especially ones that cause systemic problems like corticosteroids or antipsychotics, becomes ethically and clinically problematic. This essay explores the ethical tensions inherent in long-term drug treatment ,legal standards, and a real-life clinical scenario.

Long term Pharmacotherapy remains a principle strategy in chronic disease management, yet the sustained use of many medications has considerable and well documented risk. For instance a meta analysis of over 15,000 patients found that prolonged use of second generation antipsychotics was found to be linked to weight gain, dyslipidemia, and insulin resistance: all components of metabolic syndrome that substantially elevate cardiovascular risk. (3.)While oral corticosteroids(OCS) used in treatment of respiratory conditions such as Asthma and Chronic obstructive pulmonary disease (COPD) have been proven to cause Osteoporosis, increasing fracture risk, Cushing’s disease, Insulin resistance & steroid induced diabetes. (4) A population study done in the UK found that the incidence Osteoporosis was increased by 1.56–3.38.(4)The american journal of cardiology also published a paper that found that patients with COPD on OCS had increased risk of cardiovascular disease. (5)Despite these risks, these medications are often crucial for disease control, forcing physicians to weigh the therapeutic benefits against the cumulative harm. The ethical dilemma then lies in the tension of the Adverse effects that arise from long term use vs the clinical necessity. Especially in patients unable to grasp the eventual harmful outcomes and make a fully informed decision.

Beauchamp and Childress’s Four Principles of Biomedical Ethics: autonomy, beneficence, non-maleficence, and justice (6) States that Autonomy allows patients to make decisions about their care while beneficence requires clinicians to promote patient welfare and non-maleficence demands they avoid causing harm and justice ensures fair distribution of healthcare resources. These principles are found to be conflicting in the justifying continued use of Long term pharmacotherapy despite adverse effects. For instance in the case of OCS used for respiratory exacerbations may provide a benefit to the patient, Beneficence. However, the long term adverse effect of cushing syndrome can be considered to be doing harm which goes against non-maleficence. Additionally the limited availability of new drug therapies such as Biologics, can be considered a direct contradiction to justice. As some patients will not be able to afford experimental and expensive drug therapies.

Patient History:

Part A: The medical History.

Patient: Mrs. X

Age: 49 years

Source of History: Patient interview, Patient Medical notes.

Presenting Complaint:

• Patient presented to A&E with 1 week of productive cough and Shortness of breath.
• Patient attempted oxygen driven nebulizer at home before Presenting at A&E
• Severe Dyspnea unable to walk.
• Patient Felt Light Headed.
• Back pain
• Recently stopped taking 10-20mg prednisolone 4 Days ago.”Steroid Tapering”.
• No Fever,
• Chest pain and discomfort since the day before the presentation.

History of Presenting Complaint (HPC) Characteristics of symptoms:

• Site: pleuritic chest pain & SOB
• Onset: Walking up the stairs
• Character: sharp pain on inspiration
• Radiation: No radiation
• Alleviation: When given oxygen pain was relieved
• Time (duration/past experience of symptoms): 2 weeks
• Exacerbation: When climbing stairs or doing heavy housework
• Severity: 7/10Context:
• Patient presented 4 days after following the steroid tapering plan initiated by her respiratory consultant.
• Patient admitted to not taking ICS+LABA inhaler AirBuFo (Budesonide/Formoterol) as she felt there was no need as she was not coughing or short of breath.
• Patient did not understand the difference between her reliever and maintenance inhalers.
• Patient does not understand her inhaler regime
• 6th hospitalization due to asthma exacerbation
• Similar presentation for every hospitalization. Post steroid tapering.

Response to symptoms: Patient now works from home due to multiple exacerbation affecting her availability.

Patient’s ideas, concerns and expectations (ICE):

Ideas:

• She believes her problem is from the oral steroid cessation.
• She believes there is no need for oral steroids and inhaled steroids at the same time when she is not coughing.
• Patient believes she never had asthma and that it started from a cough, says doctors found a bug in her lungs which the side effect is asthma.
• She was told after treating her infection to kill the virus/bacteria her asthma would improve.

Concerns:

• Patient does not understand how her Revlar(Vilanterol and Fluticasone – ICS + LABA) inhalers works, Her friend told her it was for heavy smokers.
• She does not want to be a guinea pig. She doesn’t want to inhale something she doesn’t understand.
• She’s fed up after 7 years and wants to be healed and not keep trailing medications.
• Believes her infection cropped up after taking the COVID Vaccines.
• Used to be up to date with her vaccinations including the influenza vaccine, but has now stopped taking any vaccinations due to scepticism
• She was previously offered antihypertensive medication to help with diabetes control but stopped them on her own because she does not have hypertension.
• Feels like a guinea pig.
• Current concern: when is she going to be cured.

Expectations:

• Believe that an injection( possibly monoclonal antibodies?) will provide her cells so the asthma will be controlled.
• Believes post injection in 1-2 years she will be healed.
• Expectations from current hospital visit: wants something to be done to prevent exacerbations when she isn’t on steroids. However doesn’t want to take a maintenance inhaler.

Past Medical History (PMH):

1. Medical

• Diabetes mellitus: was previously well controlled, got diabetes after gestational diabetes.
• Diabetic retinopathy
• Cushing’s disease
• OSA

1. Surgical

• Laparoscopic surgery for endometriosis to help with fertility
• Uterine packing for post-partum Haemorrhage.

1. Obstetric

• Endometriosis
• 2 children.
• Post-partum Hemorrhage.
• Gestational diabetes

Medication History:

• Allergies: Cotrimazole & penecillin
• Lucreas 1 Tab BD
• Jardiance 25mg Daily
• Montelukast 10mg NOCTE
• Magvit+B6 1 tab daily
• Atrovent 0.5mg 6 hourly
• Optibac 1 Tab daily
• Omperazole 20mg Daily
• Relvar 184/22 1 puff Daily
• Moxifloxacin 400mg Daily
• Doxycyline 100mg BD twice daily
• Gliclazide SR 30MG 2-0-2 indefinite

MDT:

• Endocrine -> Poor diabetic control due to long term oral steroid use
• Ophthalmology-> Spots in her eyes (diabetic retinopathy)
• Dental -> recurrent fillings
• Physiotherapy-> chest physio for septum removal

Family History (FH):

• Mother had hypertension

Social History (SH)

• Currently lives with her husband and 2 kids
• Doesn’t drink or smoke.
• No recreational drug use
• Has a pet cat. (has been allergy tested negative)
• Works remotely as a clerk.
• Previously worked in hospital adminsteration.

Review of Systems (ROS):

Abdominal: Denies Abdominal pain, change in bowel habits.

Cardiovascular: Reports no palpitations or fatigue.

Urinary: Denies lower urinary tract symptoms

Muskuloskeletal: Denies any joint pain or swelling.

Dermatological: No rashes.

Travel history:Travels every summer ( around Europe i.e. Slovenia , Italy etc..)

And attached is the Examplar A+ standard: