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What can we say on prescription meds?

People who come to my 90-credit Comprehensive Lactation Course are sometimes surprised by the steady diet of ethics that I feed them. Perhaps that is why I receive some very interesting ethics questions from course participants months (even, years) afterwards. I admit it: I am by no means the be-all and end-all of ethical issues and answers, but I do enjoy the challenge of a good question.

So, consider this, following question I received:

I currently work with three IBCLCs at my facility and we have had some discussion about how much advice we can give about medications. The discussion has been sparked by our understanding of the most recent IBCLC Code of Professional Conduct (CPC).

Two of the four of us say that it is acceptable to print out information from credible sources or give the manufacturer’s package insert that accompanies the drug. However, our newest IBCLC says that according to the CPC, we may give the information to the physician, and then it’s up to the physician to tell the patient whether the drug is compatible with or contraindicated while breastfeeding. Can you help to clarify this?

With the above scenario in mind, I have read the IBLCE’s Scope of Practice (Sept. 2012) and Code of Professional Conduct (Nov. 2011) statements several times, and I urge you to read and re-read the documents, too. I cannot see where there is any directive to the IBCLC to prohibit her from giving information to the mother.

Let’s review the relevant passages. From the Scope of Practice: “IBCLC certificants have the duty to provide competent services for mothers and families by providing evidence-based information regarding a mother’s use, during lactation, of medications (over-the-counter and prescription), alcohol, tobacco and street drugs, and their potential impact on milk production and child safety . . .” To me, that statement
says that not only is the IBCLC ALLOWED to give such information to the mother, she has a DUTY to do so!

The text of the Code of Professional Conduct concurs, stating: “Every IBCLC shall: … Supply sufficient and accurate information to enable clients to make informed decisions … [and] Convey accurate, complete and objective information about commercial products.”

Of course, the newly-minted IBCLC colleague may have the right intentions. She may be trying to provide the doctor with information prior to providing the mother with the information. If I were the doctor, I would not want the IBCLC to go around telling patients information that I was unaware of, or information that might change my clinical management. I imagine that your colleague is trying to avoid the situation of making the doctor look dumb or feel as though he has been blindsided. Perhaps her aim is to approach colleagues in a respectful, helpful manner before giving the patient information that makes her look good and makes the doctor look bad. Creating an adversarial situation with the doctor doesn’t accomplish anything, and is just plain rude, so this is an understandable goal.

There is also the case of the package insert. If the mother had a prescription for the drug filled at a pharmacy, she would have received the insert, or very similar materials, with the prescription. If she has looked up the information on the Internet, she could have seen the manufacturer’s package insert information. Whether the mother gets it from the IBCLC, the pharmacist, or from the Internet seems unimportant. If she really wants that information, she can get it! And, if she wants to find the information in a book or in a journal, she could do that, too. Why should we withhold information she could easily obtain?

There is, however, a clear distinction between giving INFORMATION and giving ADVICE. The IBCLC cannot ever, ever give advice, since that requires a decision about risk-benefit, unless she holds a state medical license that allows her to do so. She cannot interpret, summarize, paraphrase, or otherwise alter the information. She may quote the source verbatim, or simply supply the mother with the published material.

Perhaps the new IBCLC is confusing “information” with “advice.” She is not qualified to give advice; I’m not an attorney, but I think most authorities would agree that giving advice about whether or not the drug is safe for the breastfeeding infant is tantamount to practicing medicine without a license. The person who has prescriptive privileges and manages the care of that patient has the legal right to make risk-benefit decision. The IBCLC may provide information but not weigh the risk-benefit and make such a decision.

In summary, this comes down to a duty to provide evidence-based information to the mother, a commitment to good manners, and the recognition that information about medication is very different from advice about medication risk-benefit. According to IBLCE, we are ethically bound to provide the former—but providing the latter is outside of our scope of practice.

Although I feel confident in my interpretations of these documents, I will say what I always preach in class: Never hesitate to go to the primary source!  If you have questions, please contact the IBLCE directly.

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