Introduction - To the besotted poet, love is intoxicating, exrating, invigorating. In contrast, nearly one third are more nuanced in their view. Ethicists, such as Dr. Many make the important distinction that the intimacy or longevity of the professional relationship plays a large role in determining the ethics of the personal one. Not every patient interaction with a physician is emotionally deep, nor is there an innate imbalance of power. A patient may well have a closer, more dependent relationship with her auto mechanic than with the dermatologist she once visited to have a plantar wart removed.
This differential is exacerbated further by any imbalances arising from the other three sources of power. Charismatic power may not always be less on the patient's side depending on the personalities of patient and doctor. Equally, Social power may vary in doctor- patient relationships depending on the social status of the individuals.
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This may also relate to the gender roles of the patient and doctor. The large majority of cases of sexualization occur between female patients and male doctors.
Therefore, the onus of responsibility for controlling the power imbalance in an ethically correct manner is always on the doctor. However, what is the relevance of this analysis to relationships with former, not current patients?
Several points can be made. Information gained in such a power imbalance can be artificially intimate-one does not normally begin to discuss details of sexual function within a few minutes of meeting a stranger, for example, but this frequently happens in general practice consultations. Secondly, given the strength of Hierarchical power in determining one's overall power in the doctor-patient relationship as illustrated by the case historyit is hard to see how a relationship of equals could develop from such unequal beginnings.
How should a claim be judged that a former patient gave his or her free consent before entering into the relationship? The validity of consent of a former patient, as opposed to a current one, is a little more debated, but evidence is against that being a former patient materially alters the situation.
Not all authors condemn sexual relationships with previous patients however. Zelas is a little less prohibitive. In the earlier discussion, it was argued that the power imbalance of the doctor-patient relationship would continue into the sexualized relationship. Other arguments support the idea that meaningful consent is an impossibility in this situation. Traditional teaching of informed consent emphasizes the importance of autonomous choice, i.
Doctor patient ethics dating
Leaving aside the provision of information presumably such information should include a review of the current known research in this area, although this apparently rarely, if ever, happens 12this discussion will concentrate on coercion and impaired capacity.
Coercion can arise from imposed restraints on any or all of three types of autonomy: autonomy of thought or the ability to think for oneself, autonomy of will or the freedom to make a choice based on one's own deliberations, and autonomy of action or the freedom to enact one's choice physically. However, an alternative definition of autonomy which centres upon the importance of one's social relationships demonstrates a more subtle source of coercion.
Brody argues that the distinguishing characteristic of general practice ethics, as opposed to hospital-based ethics which involves a time-limited decisional focusis the longitudinal relationship which develops between doctor and patient. From both these arguments, then, it can be seen that attention to relationship is particularly important when considering general practice ethics. It could be argued, therefore, that general practice has a particular duty of fostering the autonomy of the patient and that a GP's actions should be evaluated in the light of this duty.
Sexual misconduct with a former patient does not, by any established evidence, foster patient autonomy, and a doctor participating in such a relationship is thus breaching this duty. It would be the minority of consultations, especially in general practice, where the above conditions of persistent transference and power imbalance did not exist.
Certainly the onus of proof, in any disciplinary hearing, would lie with the doctor to demonstrate how these ethical issues were of minimal impact in the subsequent sexualized relationship. Only in situations where there was a minimal potential for transference-counter-transference to arise, together with an unusual equality of power, could the former patient be in a position to exercise true autonomy and choice when entering into a sexualized relationship with the doctor.
In general, the criteria by which the New Zealand Medical Council will judge the ethical acceptability of sexual relationships with former patients 7 appear to be necessary, but not sufficient. They have correctly identified several situations where the likelihood of significant and persistent transference-counter-transference, and the perpetuation of a significant power imbalance in the relationship, is very high.
However, other situations may well occur which fall beyond these criteria but nevertheless have a similar degree of transference-counter-transference and residual power imbalance so that a sexualized relationship is equally as abusive as the listed criteria. It is these underlying factors, rather than any more superficial descriptors, by which the ethical acceptability should be judged. This being the case, relationships with former patients should not be regarded as ethically permissible except under such rare circumstances.
The author wishes to thank Dr Chrys Jaye for reviewing an earlier draft of this paper and for her very helpful comments and suggestions. New Zealand Medical Council. Cullen RM. Medical discipline and sexual activity between doctors and patients. NZ Med J ; : - Sexual activity between doctors and patients [letter].
White G. NZ Med J ; : Cullen R.
When Patients Make 'Bad' Choices: Treatment Decisions - UCLA Health Ethics Center
Medical discipline and sexual activity between doctors and patients [letter]. Northwood B.
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The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry ; : - Simon RI. Therapist-patient sex. From boundary violations to sexual misconduct. Psychiatr Clin N Am ; 22 : 31 - Physician-patient sexual contact: ethical and legal issues and clinical guidelines.
J Fam Pract ; 36 : - Transference in therapist-patient sex: the illusion of patient improvement and consent.
Part II. Psychiatr Ann ; 24 : - Fahy T, Fisher N. Sexual contact between doctors and patients almost always harmful. Br Med J ; : - Dreiblatt IS. Health care providers and sexual misconduct. Fed Bull ; 79 : 8 - Physicians disciplined for sex-related offenses. J Am Med Assoc ; : - Evaluation of sexual misconduct complaints: the Oregon board of medical examiners, to Am J Obstet Gynecol ; : - A survey of physicians' attitudes and practices regarding erotic and non-erotic contact with patients.
Zelas K. Sex and the doctor-patient relationship. NZ Med J ; : 60 - Feldman-Summers S. Sexual contact in fiduciary relationships. In Gabbard GO. Sexual Exploitation in Professional Relationships.
Brody H. The Healer's Power. McMillan J, Anderson L.
Knowledge and power in the clinical setting. Bioethics ; 11 : - Sexual intimacies after termination: clinical, ethical and legal cts. In Gabbard GO ed.
The relationship between a patient and a physician is based on trust, which gives rise to physicians' ethical responsibility to place patients' welfare above the physician's own self-interest or obligations to others, to use sound medical judgment on patients' behalf, and to advocate for their patients' welfare. Doc, nurses and other health professionals can't date their patients, because of the inherent inequality in a doctor-patient relation, for the same reason neither can teachers date their students, lawyers their active clients. Docs that do are disciplined by the disciplinary board, usually after the . A physician must terminate the patient-physician relationship before initiating a dating, romantic, or sexual relationship with a patient. Likewise, sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician-patient relationship.
Epstein RS. American Psychiatric Association. Sexual misconduct in the practice of medicine.
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Gillon R. Autonomy and the principle of respect for autonomy. Nedelsky J.
Reconceiving autonomy: sources, thoughts and possibilities. Ramsey was.
However, as the conversation continued, the women discovered that they both had slept with Dr. Later, the women found out about a third woman with whom the D.
Further complicating the issue, a fourth woman claimed that Dr. Ramsey had a sexual relationship with her-a claim that Dr. Ramsey vehemently denied. The women decided to take action.
During a hearing that took four sessions before the chiropractic board of examiners, Dr. Ramsey was found guilty of four counts of sexual misconduct, and his license was suspended for two years.
Feb 15, The AMA notes that the prior doctor/patient relationship may unduly influence the patient and that such a relationship is unethical if the doctor "uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship.".
At the end of two years, he could apply for reactivation of his chiropractic license if he:. In addition, as a result of a civil action brought by the four women, Dr. Ramsey had to pay each claimant an out of court monetary settlement.
The resulting publicity severely affected Dr.
Ramsey had to hire a new graduate to keep his practice open during the suspension. However, Dr. Ramsey was required to remove the doors to his office, have a female on staff observe all of his treatments with female patients, and make other changes to his office policies before he could practice again.
Ramsey returned to his practice with the associate doctor who is now his partner. Ultimately, the practice was able to prosper again, but only after Dr. Ramsey learned a costly lesson and paid an enormous personal, financial, and professional price. The most important point is to never become involved with a patient or employee. If a sexual relationship is inevitable, the patient or employee can no longer remain your patient or employee.
The person must be referred to another doctor for care or dismissed as an employee. Note: Some states never permit a doctor to date a former patient-no matter how much time has elapsed. Claiming the relationship was consensual is not a viable defense. There is an inherent imbalance of power in a doctor-patient relationship, not to mention in an employer-employee relationship. Doctors are held to higher professional and ethical standards than the rest of society.
Due to the caring nature of our profession, doctors sometimes become involved in the personal problems of patients and employees rather than keeping these relationships on a professional level. This scenario can lead to inappropriate involvement with a patient or employee.
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This assumption has proven false time and time again-with catastrophic results for the doctor. Any use of real names is purely unintentional. Get a Quick Quote. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care.