Thanks for your point of view. I think it makes for a good discussion.
Some thoughts that I have on your post:
Sex is an important part of life. I'm not saying that I plan to be a blue pill mill, but I don't see the fact that a patient may enjoy use of the medication to be a reason not to prescribe, all else being satisfactory.
At what point do you draw the line? If a patient came to you and said, "I need testosterone. I'm an otherwise healthy 20 year old male, but I want testosterone so I can get big muscles and attract women." He doesn't strictly NEED it. Everything else functions appropriately. But he wants it because he would "enjoy" its use. Now, granted, testosterone carries a lot more risk than Viagra, but a lot of people take it without any issues, so why shouldn't he?
(This is not a hypothetical patient, BTW - I live in Miami Beach and there are a lot of patients here who buy steroids off the internet so that they can "get cut.")
Or, another example that I see frequently in Miami - a woman comes to you, asking for weight loss pills (Phentermine). She has a BMI of 23.5, but she doesn't feel "skinny enough," and is having trouble shedding "the excess weight" through diet and exercise. She doesn't have the money for a personal trainer, and she doesn't have the money to fly to the Dominican Republic or Colombia for cheap liposuction. Do you give her the weight loss pills? She doesn't need it, clearly, but she would certainly enjoy its use.
I thought of a different comparison. Would you hesitate to prescribe an H2 blocker or other acid reducing medication to a young, healthy person without structural cause for reflux, when you and they both know that it would abate if they "just" lost 40 pounds and stopped washing down their jalepeno pizzas with big mugs of irish whiskey laced coffee? Life style changes could absolutely solve their problem, but who wants to live without caffeine and spicy food? And while reflux can lead to more serious issues down the line, for many people like my example, it is just an occasional nuisance. So for them, acid reduction is kind of "recreational." Those drugs are not all benign, but they are handed out without any of the qualms that accompany sildenafil.
I don't think that this is a fair analogy, actually. GERD really really fricking hurts, and it actually can be debilitating. You can't sleep, you burp a lot (often during inopportune times, like business meetings), and heartburn really does make you feel like you're having a heart attack.
The patient described in the original scenario CAN have sex. He can have an erection - maybe it's just not as robust as it used to be, but it still works. His refractory time is longer, so he can't have sex as often as he wants, but he can still have sex. It's not like he can't have sex at all, without the medication. There's nothing debilitating about his situation, except for whatever harm it does to his psyche and/or ego.
To be perfectly honest, I will tell you that some of my personal resistance to prescribing Viagra for recreational use is based on my experience with these types of patients. My experience is certainly not universal, but my past experiences with these types of patients have been....irritating. These patients that I have seen have all been either a) very rude (there's no need to call my medical assistant "fat and slow" because she didn't call you back to the room right away) or b) filled with a somewhat misogynistic false bravado that I don't appreciate. ("I certainly don't NEED Viagra....everything works GREAT....but it makes sex better. It keeps all of my women happy....as long as they don't find out about each other, amirite? Hahah! *nudge nudge wink wink*") It also didn't help that whenever I refused to write the script, I was told some variation of "Well, little girl, you clearly don't understand because you clearly have never had sex, but someday you will and you'll understand." I wish I were kidding or exaggerating, but sadly, I am not. It's like 4Chan, come to life.
I just see my role as one of promoting my patients best interests as determined by their wishes for themselves.
I think that that's a great goal to have as a physician. I will say, however, that you have to have some boundaries. If you don't, it will be easy to get pushed back, slowly, until you hit some brink of "oh s***, what am I doing?" And an easy boundary to set for yourself is, "Does this patient truly need this medication? What MEDICAL indication am I writing this for?" The ability to have sex 4 times a night instead of just 1 is not really a compelling medical indication.