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Doctor romantic relationship with patient

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Katherine H Hall; Sexualization of the Doctor romantic relationship with patient relationship: Whilst having sexual relationships with current patients is clearly unethical, the ethics of such a relationship between a doctor and former patient is more debatable. In this review of the current evidence, based on major articles listed in Medline and Bioethicsline in the past 15 years, the argument is made here that such relationships are almost always unethical due to the persistence of transference, the unequal power distribution in the original doctor—patient relationship and the ethical implications that arise from both these factors especially with respect to the patient's autonomy and ability to consent, even when a former patient.

Only in very particular circumstances could such relationships be ethically permissible.

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Sexualization of the doctor—patient relationship: Family Practice ; All codes of ethics set up by medical professional bodies prohibit sexual relationships between a doctor and a current patient. Although this stance initially provoked a degree of controversy within the country, 2— 6 the deleterious effects of such relationships upon patients have become increasingly recognized and condemned by the medical community. However, some areas of debate do still remain.

One such area is whether sexual relationships with former patients are ever ethically permissible and, if so, under what circumstances. This paper presents evidence from international medical and ethical literature to examine the validity of this position taken by the New Zealand Medical Council regarding the sexualization of relationships with former patients.

First, the concepts of boundaries and transference are discussed and a profile of the medical practitioner at risk of offending is drawn. Secondly, three aspects Doctor romantic relationship with patient the doctor—patient relationship are explored: Thirdly, a discussion of the role of autonomous choice and consent is presented. Many boundaries exist in the doctor—patient relationship. These include boundaries of role, time, place and space, money, gifts and services, clothing, language and physical contact.

Not all stages will take place in any one relationship, but the general stages include: This does not mean that no such type of relationship may exist, but it has not been researched.

This suggests that the overwhelming outcome for most, if not all, patients is negative. However, the crossing of boundaries per se does not necessarily mean that an unethical act occurred: Nor Doctor romantic relationship with patient all boundary transgressions between doctor and patient ultimately lead to sexual misconduct.

Clues as to what these other factors should be can be gleaned from examining the profiles of offending doctors. A key factor in the identification of doctors at risk of violating boundaries is the enhanced vulnerability of a doctor to the transference—counter-transference dyad which occurs in varying degrees in every doctor—patient relationship. Doctors can mistake the feelings of love that arise in a therapeutic relationship as being the same as love that arises elsewhere; it is not.

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Therefore, unmet emotional needs of the doctor, overidentification with the patient and particularly intimate areas of medicine associated with long-term professional relationships with patients can all potentially enhance the strength of the transference—counter-transference relationship between doctor and patient.

Transferences per seas with boundary crossings, also occur in normal love relationships, 12 and therefore are also a necessary but not sufficient condition for ethical unacceptability. However, it is the existence and persistence of this type of transference, linked with the fiduciary relationship and unequal power structure, which makes most relationships with former patients ethically unacceptable Doctor romantic relationship with patient following sections.

The fiduciary relationship relationship of trust is a crucial aspect of the doctor—patient relationship. In turn, to build such a relationship, the unequal power distribution between doctor and patient has to be acknowledged and contained in an ethically correct manner. The onus of responsibility for this last task falls on the person who has the most power in the relationship which, as I will argue, is always the doctor. To explain why this is always the case, even with former patients, it is useful to consider the sources of medical power in light of a framework suggested Doctor romantic relationship with patient family practitioner and ethicist, Howard Brody.


In his book The Healer's Power20 Brody outlines three sources of medical power: Aesculapian, Charismatic and Social. It has also been suggested that another source of power —Hierarchical power, the power inherent by one's position in a medical hierarchy e. To help understand these four types of power, and the relationships between each type, consider the following incident from my personal experience as a first year house surgeon in Australia in the mids.

Although it does not involve the sexualization of the doctor—patient relationship, it clearly illustrates the importance of recognizing all four types of power, and, in particular, the prominence of Hierarchical power: A consultant specialist was admitted to hospital with a severe multi-system disease causing severe renal Doctor romantic relationship with patient.

After 6 weeks in hospital, on the day of his planned discharge, he was accidentally given another patient's medication. Instead of receiving his azathioprine and corticosteroids, he was given a high dose of frusemide and captopril.

Doctor romantic relationship with patient Despite having the Aesculapian power of a doctor, and the Social power of a hospital specialist, in addition to considerable Charismatic power he was a well-liked and respected colleaguenone of these were sufficient to counteract his lack of Hierarchical power by being a patient.

Simply by the sheer nature of taking on the role of patient, regardless of any other type of power, there is always an unequal power differential between the doctor and patient.

This applies in both general practice and hospital-based medicine, although it may be accentuated by the latter's institutional culture.

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However, there is also the question of whether this type of power would be accentuated further in a fee-for-service situation, as exists in general practice in Australasia, as opposed to free public hospital treatment. This differential is exacerbated further by any imbalances arising from the other three sources of power.

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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 Doctor romantic relationship with patient function within a few minutes of meeting a stranger, for example, but this frequently happens in general practice consultations.

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Secondly, given the strength of Hierarchical power in determining Doctor romantic relationship with patient 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 Doctor romantic relationship with patient 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.

Transferences can persist indefinitely and with it the perpetuation of the potential or real incompetence of the patient to recognize these feelings for their true nature and the same for doctors with respect to counter-transference: There is no empirical research to demonstrate that transference disappears for the patient or even simply decreases with cessation of the doctor—patient relationship or counter-transference for the doctor although this is less studied: Not all authors condemn sexual relationships with previous patients however.

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Zelas is a little less prohibitive. Even with this broad guideline, however, Zelas also states that: In the earlier discussion, it was argued that the power imbalance of the doctor—patient relationship would continue into the sexualized relationship.

Meaningful consent to a Doctor romantic relationship with patient relationship cannot be given in a situation of unequal power: 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. 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: 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 Doctor romantic relationship with 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 Doctor romantic relationship with patient conditions of persistent transference and power imbalance did not exist.

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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 Doctor romantic relationship with patient 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.