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Medical Ethics : When Is It Okay to Date a Patient?

Discussion in 'Doctors Cafe' started by Egyptian Doctor, Jan 2, 2014.

  1. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    Introduction

    To the besotted poet, love is intoxicating, exasperating, invigorating. To the doctor -- if the would-be paramour is a patient -- it's also unethical.

    But physician responses to Medscape's 2012 ethics survey clearly indicate that many physicians aren't willing to condemn every romance. When asked, "Is it ever acceptable to become involved a romantic or sexual relationship with a patient?" more than two thirds (68%) of the 24,000 doctors who responded resoundingly say "no."

    In contrast, nearly one third are more nuanced in their view. Only a tiny minority (1%) give romance with current patients a green light, but a sizable share (22%) say that a romantic relationship with a former patient may be acceptable, as long as at least 6 months have passed since the professional relationship was terminated. Another 9% say the ethics depend on the situation.

    Whereas the American Medical Association (AMA) clearly states that sexual contact that is concurrent with the doctor/patient relationship constitutes sexual misconduct, it takes a fuzzier position on relationships that might develop later. 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."

    Ethicists, such as Dr. Richard Martinez, director of forensic psychiatry services at Denver Health Medical Center and the author of several articles on ethical decision-making and the patient/physician relationship, says the AMA was wise to leave a little wiggle room in its opinion.

    "Relationships are complicated," he says. "Every ethical dilemma has to be evaluated and considered on a case-by-case basis."

    When a Potential Romance Depends on the Circumstance

    That simple "it's complicated" answer captures the spirit of nearly one third of the respondents' remarks. Whereas many qualified their answers with caveats that they themselves would not engage in such a relationship and that "99.9% of the time" having a relationship with a patient is verboten, "there are weird instances in life when I can see this happening," wrote one general surgeon. "Of course, the physician-patient relationship would have to end."

    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. Similarly, a patient may not even remember the anesthesiologist who presided over his gallbladder surgery or the emergency department doctor who once stitched his finger.

    "I think it depends in part on the type of physician and medical care," says a pediatrician. "For example, I would be less concerned about an ophthalmologist getting involved with a patient who has had general yearly visits than I would an internist or oncologist."

    Likewise, "the fact that you met them as a patient once in an ER, or you cared for them years ago and they are no longer your patient should not be absolute barriers to a relationship if it develops," wrote an obstetrician/gynecologist.

    Ethicists say the distinction is valid. Some specialties by their very nature create a more intimate relationship, and one that makes the patient more vulnerable. Recognizing that, the American Psychiatric Association categorically prohibits sexual relationships with either current or former patients.

    The difference between treating a "boo-boo" -- as opposed to a patient's depression or cancer -- can't be overstated, says Kenneth Goodman, PhD, codirector or the University of Miami Ethics Programs.

    Dr. Martinez agrees. "You definitely have to dissect the relationship," he says. Whether or not a relationship could be ethically defensible depends on the nature, intensity, and frequency of the doctor/patient interaction, he says.

    A handful of respondents note that an amorous relationship with a patient might be allowable for physicians in rural areas, where everyone's a patient, but such ethicists as Dr. Goodman are less sympathetic and advise country doctors to "find someone in the next town over," rather than muddy the legal and ethical waters.

    Is 6 Months Too Soon Before Dating a Patient?

    Because relationships morph with time, it's often difficult to define starting and stopping points. Does a coincidental meeting at a cocktail party where you engage in a personal conversation constitute the beginning of a relationship? What if you attend the same church? Play in the same tennis league? Have children in the same school? The boundaries between friendship and "something more" aren't always clear.

    Strangely, determining when the professional physician/patient relationship is over can be similarly murky. Many such relationships simply atrophy with inattention. If a patient is healthy, he or she doesn't visit the doctor. Sometimes for years, sometimes forever. But is the relationship over?

    For many physicians, "once a patient/doctor relationship, always a patient/doctor relationship," says Dr. Martinez. "I think that's what sits behind the 68% of 'No/Never' responses."

    As one podiatrist notes, "I have had patients return to my practice after 5 or 10 years, so they never stopped being patients really."

    Others insist there has to be some logical point of demarcation between current and former patients. "If someone was once a patient, left the practice and left town, was out of touch for years, and then returned not as a patient and kindled a relationship, I think that would be acceptable," writes one internist.

    But many respondents were uncomfortable with the 6-month waiting period spelled out by the question, insisting it was either too arbitrary or too short. Even though they answered "yes" to the question under those circumstances, they insisted that the wait should be a matter of years, not months.

    Others insisted the difference between a current patient and a former one -- at least when it comes to romance -- depends on a formal letter terminating the professional relationship. Still others noted that a shift in role is more important than the time frame in which that shift occurs.

    "The critical issue is the change from being a patient," writes a general surgeon. "Six months seems arbitrary. It is the termination of the doctor/patient relationship that is essential." A family practice physician expresses a similar sentiment: "I don't know what the magic number of months is that should pass after the doctor/patient relationship has ended. But it must be ended beyond all doubt, for a substantial period of time, before a romantic or sexual relationship can begin."

    Cautious Behavior Doesn't Always Protect You

    Although the ethics of a relationship may be situational, a wrong decision could work against you if any court-related issues subsequently arise.

    "The point of ethics is not to be safe," Dr. Goodman says. "It's to promote thoughtful, reasoned decision-making. It's not personal risk management."

    Consequently, whereas one physician might harmoniously pursue a relationship with a former patient, another physician may not be so lucky. If the relationship doesn't work out the way the patient wished, he or she could bring charges against the physician -- even if it was the patient who initiated the relationship -- and that can present big problems for the physician.

    Bruce Vande Vusse, a Michigan-based healthcare litigator, notes that "These things only come out in situations where somebody is unhappy -- whether it's a former patient or a jilted spouse, or some concerned character who blows the whistle and says the relationship is improper. However the fuse gets lit, the provider is going to be starting on the defensive."

    Vande Vusse cautions physicians against any involvement with current patients -- "that's a Mount Everest to overcome" -- and calls 6 months "way too short a waiting period to say 'proceed without risk.'" As for the risks, they include possible money judgments, loss of society membership, license revocation, and more serious consequences.

    Even a well-considered relationship -- one that includes a formal letter terminating the doctor/physician relationship, knowledge that another physician had assumed care, and a lengthy waiting period before a romance -- can present obstacles due to the foibles of memory and the motivations of others, Vande Vusse says.

    For many would-be Romeos and Juliets, those risks and the potential consequences are enough to squelch the flame.

    "If you don't like ambiguity, the right answer is, 'No, never," says Dr. Goodman. "It keeps the situation a lot simpler. 'No' is the safest answer."

    For those who remain undaunted? "Proceed only with great caution," says Dr. Goodman. "If there's any area where people's judgment is impaired, it involves sex and romance. Erring on the side of caution may cost you a really hot date, but you're probably better off for it."

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