Thursday, April 23, 2009

Doctor-Patient Sex

Doctor-patient sex is in the news again.

Here's a report from the Texas Medical Board about an action it took against Dr. Kenneth Baird, a family practitioner in Plano, Texas (see here and here for information about Dr. Baird)
On April 3, 2009, the Board and Dr. Baird entered into an Agreed Order requiring that, within one year, he complete the professional boundaries course offered by Vanderbilt University or the University of California San Diego Physician Assessment and Clinical Education (PACE) program; that for each of the next two years he obtain 10 hours of continuing medical education in ethics; and that within 180 days he pay an administrative penalty of $10,000. The action was based on Dr. Baird’s having had a sexual relationship with a patient.
Two things interested me about Dr. Baird's situation. First, he's not a psychiatrist! It's a relief not to have one more sorry example of misconduct from my own specialty. Second, the case points us to an important question - if sex between doctor and patient is seen as wrong, what makes it wrong?

The common answer is that sexual involvement harms the patient. We know from individual cases that this is often true. But even if doctor-patient sex is harmful in 99% of the cases, it's hard to see why it is always harmful. And if we can identify or imagine situations where it is not harmful, does that make those situations ethically acceptable?

In 2008 the Texas Medical Association rendered an opinion that appears to make use of emotions or insights derived from the doctor-patient relationship the key factor:
SEXUAL MISCONDUCT. Sexual contact that occurs concurrent with the patient-physician relationship constitutes sexual misconduct and is unethical. Sexual or romantic relationships with current or former patients or key third parties are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the professional relationship. Key third parties include, but are not limited to, spouses or partners, parents, guardians, or proxies.
Harm to the patient and exploiting the clinical relationship for personal gratification are clearly reprehensible. But since these factors are probably not present in every case they do not provide a basis for an absolute prohibition.

The Texas Medical Association would have done better if they had gone back to Hippocrates:
With purity and with holiness I will pass my life and practice my Art...Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.
Hippocrates based his prohibition of doctor-patient sex on the intrinsic responsibilities of the medical profession, not on the consequences of seducing male or female members of the house the physician entered. As a member of the medical profession the physician professes a set of values. Hippocrates' terms "purity," "holiness" and "for the benefit of the sick" hold up very well after almost 2500 years.

Developing a sexual relationship with a present or former patient tarnishes the profession itself, whatever its effect on the individual patient. Harm to the patient is a probable outcome of doctor-patient sex. But harm to the profession is an inevitable outcome. Patients, the public, and physicians themselves, will lose trust in and respect for the medical profession. Hippocrates explains what's wrong with doctor-patient sex better than the Texas Medical Board does. I hope this is part of the 10 hours of ethics education the Board directed Dr. Baird to take!

52 comments:

Chris MacDonald, Ph.D. said...

I think you're right to focus on the harm to the profession.
But then the question becomes, "how does it harm the profession?" If the answer is that it harms the profession because the profession is held responsible for harms to the patient, we're back to square one.

I think one way of thinking about this (not inconsistent with your focus on the profession itself) is to think of doctor-patient sex as analogous to statutory rape. In cases of statutory rape, there's no claim that the underaged person was harmed, or even that they didn't consent, or that they couldn't consent: the goal (I take it) is to protect the most vulnerable within a category of people by declaring them all, categorically off-limits.

So, the best way for the medical profession to safeguard its good name is to say that, categorically, they will not have sex with patients -- they'll rule them out categorically, rather than try to decide case-by-case, in a way that would be susceptible to self-serving rationalizations.

Jim Sabin said...

Hi Chris -

I see from your photo that you are the author of the superb business ethics blog. I regularly learn from your blog and am grateful for your thoughtful comment.

The comparison to statutory rape is a good one. In clinical practice, when my patients and I had to deal with uncertainties, as about whether a medication was needed, I often asked - "if we were to make a mistake - would you prefer starting XYZ now when time would have taken care of the problem and we wouldn't have needed it, or wait, and have the symptoms last longer if time didn't do the job...?"

If sex with patients is (a) almost always harmful to the patient and (b) susceptible to rationalization by the physician, then (c) the profession should ban it, just as society bans sex with youngsters under a certain age.

In addition to the excellent line of reasoning you propose, I see a rationale in the motivation we want the medical profession to evince. Physicians should be focused on their patients' well being. Sex is perhaps the greatest distraction from the needs of the other to the desires of the self. That's the opposite of the values the profession professes.

Best

Jim

Readers - check out Chris's blog at
http://www.businessethics.ca/blog/

Anonymous said...

what is the actual harm to the patient? I have found countless articles and sites that claim dr. patient sex is "obviously harmful to the patient." Well, I am not a medical professional and not all the reasons are obvious to me. I am however somewhat of a victim in this sort of case (with a diagnostic consultant) and am trying to understand what happened. All I know is he gave me hope and then killed it through abandonment, etc. He made lots of promises and didn't keep them.

Jim Sabin said...

Dear anonymous -

Thank you for your question and comment, and for sharing your own experience.

I'm most aware of what is known about sex between psychiatrists and patients. In that context the patient has typically consulted the psychiatrist for a highly personal vulnerability. Psychotherapy invites and makes use of "transference" reactions - feelings about the clinician that come from other segments of life, often childhood. This means that the patient's attachment to the psychiatrist is potentially even less rational than romantic and/or sexual relationships usually are, with high potential for the kinds of abandonment and betrayal feelings you describe.

Beyond that, patients place trust in their doctors to focus on what the patient needs, not on what the doctor might desire. Sexual involvement betrays the physician's commitment.

My guess is that because physicians know that sexual involvement is contrary to medical ethics, they're likelier to act badly in the relationship - either because they are unscrupulous to begin with, or out of guilt.

But as I said in the post - I think it's a mistake to assume that every patient is harmed. The examples that come to light are those in which the patient feels mistreated, so we don't know how often the patient feels neutral or positive about the experience. In my view the ethical rationale for prohibiting sex with patients is that whether or not the patient is harmed, the trustworthiness of the profession in the public's eyes is always harmed.

The relationship with a diagnostic consultant is probably significantly different than that with a psychiatrist. If you were willing to share your own further thoughts I would be most interested.

Again, thank you for your contribution to this dialogue!

Best

Jim

Anonymous said...

I was recently involved with my surgeon. I was a neighbor and employed at the time our affair took place. We now have severed our relationship due to the strain on our families. We were both married at the time. I have been in counseling for 6 months and suffer from anxiety, abandonment issues, depression, weight lose and not to mention loss of income because I felt I had to leave place of employment. What is the consequences if the AMA were ever to find out about this action? I feel I need to continue to protect him, but also would hate for this horrific event to happen to another patient.

Jim Sabin said...

Dear Anonymous -

First, I'm sorry for the painful situation you describe. Thank you for sharing it!

If I understand the situation, the doctor was (a) your surgeon, (b) your neighbor and (c) your employer. If that's correct he was in a relationship of authority in two ways - as surgeon and as employer. Both of those roles carry responsibilities which he violated.

It wouldn't be unusual for someone to feel anxious, abandoned and depressed when any intimate relationship ended. But when that relationship is with one's doctor and employer the reaction can be much more intense.

I don't know how the surgical society of the state you are in would handle a complaint brought against the surgeon. My own medical organization (Massachusett Psychiatric Society) would only respond to a complaint from a patient or colleague - not to a rumor. Certainly the physician would be disciplined, and depending on circumstances possibly expelled from the society. Even more serious, the Board of Registration could suspend a doctor's license, which would prevent him from practicing. And a hospital could take away priviliges.

Given that you are in counselling, it could be useful to discuss the dilemma you feel. In part you want to "protect" the surgeon, but you also don't want to see other patients hurt by his unprofessional conduct, as you were.

Best

Jim

Anonymous said...

There are some real slick professionals out here. The first time it happened with my Dr. I chalked it up to "give the guy a break, so he had a weak moment" incident. On my next visit, I was in much pain because my back had been out for 3 days. In my "bent over" condition, my Dr. took our "first" oral encounter to the next level, without my permission, & without warning. By the time my back was better, I'd almost convinced myself that it did not happen, except I told a friend, who told me "if it happens again, get proof or nobody will believe you". I did, & it was like dancing with the devil, but I got my proof.
Well, I reported him & made the police report, only to be told that this Dr. will not be charged for what he did, because I did not report him right away & after the first time, the Detective & Prosecutor considers all other actions as consensual. To make matters worse, my husband believes that I seduced this Dr. Because he has been my husbands Dr. for 19 years, & my Dr. for the past 6 years.
With results like this from our "JUSTICE" system, I can see why most women never report this kind of rape. This has ruined my marriage of 6 years. I can only hope that the ethics board has faced this kind of situation before.

Jim Sabin said...

Dear Anonymous

Thank you for your comment. It's a painful story.

With regard to the initial incident, I would have counseled against "giving the guy a break." Any kind of sexual advance is contrary to medical ethics and not part of an acceptable clinical relationship. And, I'm surprised that your friend didn't tell you to find another doctor.

With regard to your experience with the police, I've heard similar reactions from other women. Blaming the victim is, alas, common in many areas of life. My impression from the media is that police response to women who report rape and molestation has improved over the years. But there's still a ways to do, as your experience indicates.

From the perspective of a medical society ethics committee the issue the police apparently stressed - whether the ncounters were "consensual" or not - would be irrelevant. Sex with a patient is contrary to medical ethics, whether consensual or imposed. Obviously any kind of force makes the behavior significantly worse, but even if an encounter was 100% consensual it would still be a violation of professional ethics.

I'm very sorry the circumstances have had the impact you describe on your marriage.

Good luck to you in dealing with the painful aftermath of the experience!

Best

Jim

Anonymous said...

Hi Jim,

I was recently involved with my surgeon for about 6 months and it really left me feeling depressed, abandoned and vulnerable. Although our relationship was consensual, I do echo the sentiments of others that due to the doctor-patient relationship, the damage is deep. It also leaves me very uncomftorable to ever visit his clinic or seek any type of counseling through his office.

When I told him (the doctor) my feelings, he just told me to let it go and move on with my life. I am trying each day to move on but I thought it was all in my head of how badly hurt I felt until I read some of the others blogs. Thank you for opening this blog as it helps with the recovery.

Jim Sabin said...

Dear Anonymous -

Thank you for your note. I am VERY sorry about the painful experience you've had with your surgeon and VERY pleased that the blog has been helpful to you.

The code of ethics for all medical and surgical specialties defines sexual relationships between doctors and patients as unethical. An article in the Journal of the American Medical Association showed that the largest number of physicians who were disciplined by their professional societies for sexual relationships with patients were in psychiatry, but every specialty was involved, including general surgery.

The fact that a patient consents to a sexual relationship does not exonerate the physician's behavior. It's part of the responsibility in being a member of the profession to respect and follow its ethical guidance.

Good luck in your further recovery from your experience!

Best

Jim

Anonymous said...

My doctor of 20 years is very dear to me. We have become quite close freinds in that time.

Recently he confessed that he has for all those years had sexual feelings for me. He did so in an afterhours conversation. He has never been inappropriate in any way before this.

I have started the procedure for changing doctors which breaks my heart. I have not cut off all contact with him yet, as I would miss him so much.

At what point would he no longer be bound by doctor/patient ethics? I ask because I want to know when I can talk to others about this problem without risking his career.

Jim Sabin said...

Dear Anonymous -

Thank you for this very thoughtful comment and question.

First, it is good when strong feelings of friendship and even the "right" kind of love exist in the doctor-patient relationship. It sounds as if you have experienced the 20 years of medical care in a very positive way.

It is also not unusual for erotic feelings to occur in all kinds of situations. Your comment doesn't make clear what your doctor intended in reporting his sexual feelings. The fact that it was in an "after hours" setting implies that perhaps it was with the intent of initiating a sexual relationship. The fact that you have begun the process of finding a new doctor and use the word "inappropriate" suggests that you took it this way.

The American Psychiatric Association takes the stand that a sexual relationship with present or former patients is unethical. In other specialties there allowance for the possibility that such a relationship may not be seen as "unethical" if a period of time - sometimes 6 months, sometimes a year - has passed after the clinical relationship has ended.

With regard to your question about talking with others, you should be free to process this experience in whatever ways serve you best. The potential for harm to your former physician is likelier to come from the world of "gossip" than from any regulatory body, unless you decide that you want to lodge a complaint.

The right thing for the physician to do would be to seek consultation from wise and respected colleagues. If he experienced sexual attraction for 20 years but just now chose to act on those feelings, that might be a signal of some problem at work in his life that led to his lapse in self-management.

Again, thank you for raising such important issues.

Best

Jim

Robb said...

I met a beautiful woman at a sporting event. We are both in our fifties. I feel in love with this woman the first time I saw her and more so after I approached her and began a discussion. She also appeared to be interested in talking with me. I truly felt that I had encountered the love of my life. By a happy coincidence, she appeared at a post-game party; I once again approached her and began to discuss the game etc. We strolled around the downtown area and talked more. Returning to our table, I shared a story about some herbal supplements I was taking for insomnia; She told me that she was a chiropractor and had several practical thoughts about nutrition, diet supplements and structural corrections for improving ones health. In an attempt to continue our connection, I asked if I might visit her clinic and undergo a manipulation on my next trip into town.

I have blossomed into a lovesick child over her because of her beauty, poise, and intelligence. I love to send her flowers, love poems, messages of endearment. I am not a stalker...I have just found true love. This woman has never been inappropriate, suggestive, nor encouraging sexual contact and usually seemed reticent and withdrawn. I was puzzled. This weekend, I finally sat her down and asked if there were any chance that she had the same feelings for me.

To my amazement, I learned that she is trapped by her profession and may only treat me as a good friend as I have become her patient. She went on to explain that my discontinuing her services would not change the issue in my favor.

This is nuts. All of the intention has been initiated by me, it is true that the manipulations have helped my general attitude and health (of course simply being in her company would have effected the same response). I am in very good health now, and would never had suggested manipulations if I knew what the repercussions would be. In her defense, I do not believe she knew how I felt about her when we first met and talked about treatment. She was simply trying to bring in more business.

I have totally screwed myself...this is not fair. I do not believe she is using the boundary issue to avoid developing a relationship with me as she appears to be joyed to see me each time we meet. Is there no hope for me...can I never again hope to have her as an intimate companion. This is not fair !!!! There has to be a way to justify our future. And don't give me any bull about the sanctity of the profession here...she did nothing to encourage improper behavior...this brainstorm was all my "clever" idea and it has backfired terribly. Was she supposed to ask if I had romantic feeling about her before scheduling an appointment? Is there no cupid in the medical profession to help me out of this quandry?

Jim Sabin said...

Hello Robb -

What an extraordinary situation! Your story shows how difficult it is to have hard and fast ethical rules.

Obviously, in retrospect it would have been better to propose a date rather than a chiropractic manipulation. And for purposes of my response I'll assume that your analysis - "I do not believe she is using the boundary issue to avoid developing a relationship with me" - is correct.

I looked up the chiropractic code of ethics. Here are the two sections relevant to your situation:

"VI. The doctor-patient relationship requires the doctor of chiropractic to exercise utmost care that he or she will do nothing to exploit the trust and dependency of the patient. Sexual misconduct is a form of behavior that adversely affects the public welfare and harms patients individually and collectively. Sexual misconduct exploits the doctor-patient relationship and is a violation of the public trust."

"XIII. Doctors of chiropractic have an obligation to the profession to endeavor to assure that their behavior does not give the appearance of professional impropriety. Any actions which may benefit the practitioner to the detriment of the profession must be avoided so as to not erode the public trust."

I didn't find a definition of "sexual misconduct," but it's clear from your narrative that the woman you've fallen for hasn't exploited a patient in her practice by seeking to initiate a relationship. I'm guessing that her concern is with XIII. If that's the case, and if she indeed wishes she could (a) develop the relationship with you and (b) do it in a way that is consistent with her professional ethics, than my advice to her would be (c) to consult with the local or national chiropractic ethics committee.

This is an unusual situation in which her "patient" (you) came to her on false pretenses - as a way of continuing a relationship that had been initiated in a non-professional context. In a sense you weren't a patient, you were a (somewhat sneaky) wooer. She was offering treatment in good faith. But you weren't asking for "treatment" as much as covertly trying to make a "date."

If this is brought to the chiropractic ethics committee I would (a) wish you luck and (b) be very interested in a followup report.

Best

Jim

Anonymous said...

Dr Sabin,

Thank you for your response and attention to my question. I believe we are in agreement as to any future action. I appreciate your willingness to discuss this problem.

Robb

PS=>you were right and I should have been more direct up-front. sometimes I am too clever for my own good. In retrospect, I have never been happier...if we must, we will simply continue as good friends and I will still have her companionship.

Anonymous said...

My obgyn has been pretty much my primary care physician for the last 12 years. He delivered my son 3 years ago. He has always had a great bed-side manner and made me me feel like I was the most important patient. I had always thought this was a great skill that he was able to make all his patients feel this way. As I look back over the years, comments about my looks, my sex life, and my job as a sex education teacher just seemed like a normal part of the visits. During my last yearly exam he asked me the normal question of what kind of birth control I was using. This question got me talking about the unsatisfactory sex life with my husband...maybe I shared too much and went into too much detail. He started talking about possible solutions that included medication for my husband, toys, positions, and finally said that I may need to get a boyfriend. We were kind of laughing about that. The conversation actually turned into me hitting on him and telling him about my sexual fantasies involving him and the exam table! Still, I really didn't think things had crossed the line. None of this conversation happpened with me undressed, but rather after the physical exam. As I was leaving, he gave me a kind of one-armed hug and then turned my face to his and kissed me on the mouth. It was just a peck really, but it was obviously intentional. As he walked me out he told me that I could always call him after 5:00 at the office to speak to him directly.
I could not get him off my mind all weekend. I have actually been attracted to him for years, but we have both been married at one time or another. I decided to call on Monday and just talk. We decided to meet on Wednesday at his office and had incredible sex on his office sofa. We have meet two other times over the past month. When we are together, I can't get enough of him. He says and does all the right things. He knows I would never leave my husband; and also knows that I really want to meet with him more often. He is really busy, which I understand, but I feel like I need him much more than he needs me. I have no desire to ruin this man's practice or hurt him in any way, but I feel a little "led on" in that he knew what I was looking for in a "boyfriend" when he volunteered for the job. Any thoughts?

Jim Sabin said...

Dear Anonymous -

Thank you for your thoughtful, candid comment. In response to your closing question, I have a number of thoughts.

My focus in this blog is healthcare ethics, so that's the only dimension of the situation I'll comment on.

Your obgyn's capacity to make each of his patients feel special and important is something every physician should strive for. I can't tell whether in retrospect you believe his manner over the 12 years he's been your doctor was flirtatious and sexually inviting. Comments about looks, sex life, and your work as a sex educator could be an entirely appropriate part of obgyn care, but even if they were made with entirely professional intent (which is, in retrospect, uncertain), the intimacy of obgyn care has great capacity to elicit strong reactions, like the erotic fantasies you experienced. That's why the American College of Obstetricians and Gynecologists code of ethics is unambiguous about doctor-patient sex: "Sexual misconduct on the part of the obstetrician-gynecologist is an abuse of professional power and a violation of patient trust. Sexual contact or a romantic relationship between a physician and a current patient is always unethical."

Your comment that "I feel like I need him much more than he needs me" speaks to one of the dangers in sexual and romantic relationships between doctor-patient. The physician-patient relationship is asymmetrical. Physicians are in a position of "caring authority." That role can elicit what in psychiatry gets called "transference." The professional responsibility of the physician is to understand "transference" and manage both (a) the risks to patients and (b) our own reactions.

The fact that a patient might "hit" on the physician doesn't change a physician's ethical and clinical responsibility. Patients are entitled to express their feelings and fantasies, just as you describe. In a teaching session during my first year of residency a senior psychiatrist told of how a patient expressed a wish for romantic involvement. He responded "it won't be difficult for you to find a boyfriend if you want one, but it isn't so easy to find a good psychiatrist - that's the role you need me to be in."

The code of ethics for psychiatry differs from obgyn in an important detail. I put the key difference into bold italics: "the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical." The psychiatric profession has concluded, in my view correctly, that psychiatrists are responsible for continuing to act in a professionally responsible manner after treatment ends.

Your final comment that you "feel a little 'led on'" sounds realistic to the situation as you describe it. I'm concerned that you appear to be experiencing a sense of conflict and perhaps emerging hurt. I would encourage you to consider counselling to deal with the marital unhappiness you've experienced and the relationship that has emerged with your obgyn.

Again, thank you for your thoughtful and important comment!

Best

Jim

Anonymous said...

Please tell me how horrible it would be if i hooked up with my psychiatrist.....please tell me, PLEASE! I need to get over my physical/sexual attraction to my psychiatrist ASAP. How can I get over it?? I did tell him about my feelings and he shared with me that he is openly gay in his profession (i'm a woman) and i'm still attracted to him!!! Help!!

Jim Sabin said...

Dear Anonymous

Thank you for reaching out and raising this important question. Here are some thoughts:

(1) In terms of how "horrible" it would be for you to get involved sexually with your psychiatrist, as I've written in several posts, the profession has articulated an absolute ethical prohibition for the psychiatrist to enter into this kind of relationship. The ETHICAL responsibility rests on the clinician. The CLINICAL concern is for the patient, since relationships of this kind are usually harmful to the patient in the long run.

(2) In forms of therapy that use feelings that come up in the patient-therapist relationship as part of the treatment process, the key question is - how do these feelings (anger, contempt, distrust, sexual attraction, etc) shed light on the problem areas the therapy is intended to help with? What can be learned that helps the patient make progress? Questions like - "what makes these feelings SO intense?" can often yield useful insights.

(3) When feelings about the therapist, whether sexual or non-sexual, positive or negative, are so strong that they impede rather than advance the treatment, sometimes the patient and therapist decide to get a consultation from another clinician, or even to transfer the treatment to someone else.

(4) You've done the right thing by bringing the matter up with your therapist, and reaching out for consultation, as via the question you've posted here.

The issue you bring up isn't peculiar to you. 1:1 therapy can elicit very strong emotions of all kinds. The challenge is to use those emotions as opportunities to advance the goals of the treatment. I'd invite you to write back to let readers know what you learn from the challenging situation you've described.

Thank you again for bringing up these important issues!

Best

Jim

Anonymous said...

Let us face it squarely. There are only 4 women that a newly qualified overworked doctor intern is exposed to: a fellow doctor(usually out of reach), a nurse(may lead accusation of sexual harassment) a bar waitress(usually not of the best social character) and the patient. I chose the latter and am happily married to her for 8 years. Did I breach the ethics? Can a distinction be made between sexual attraction and real love?.

Jim Sabin said...

Dear Anonymous -

Thank you for your wonderfully succinct description of the intern's dilemma. From my experience working with primary care residents I know you're not exaggerating the demands of the internship year.

Congratulations on 8 happy years of marriage. I don't know what area of medicine you're in, and what its code of ethics states. In my own specialty - psychiatry - the code asserts that sex with current or former patients is unethical. So if you're a psychiatrist, the code answers your question - you did breach the ethics of the specialty.

The question is - what's the basis for that claim? Most writers talk about harm to the patient. But 8 years of happy marriage is the opposite of harm! As I see it, the claim that the relationship is unethical is also based on the need for the medical profession to protect its reputation. If patients fear that their doctors will start hitting on them our reliability will go down the tubes. That would be a big loss for patients and for the medical profession.

So - you may have violated the ethics of your area of medicine, but I'm guessing that you and your wife distinguished right from the start between "real love" and "sexual attraction." You have 8 years of evidence that you got it right! For you as individuals the professional ethics precept would have been a bad guide.

But it's too easy to mistake sexual attraction for real love to want to leave the door open for all interns to make the judgment for themselves. For every happy marriage like yours we'd be at risk for a lot of bitterness, broken hearts, and patient mistrust.

I'd be very interested in any further thoughts you have on the topic.

Thank you for your comment. And, again, congratulations on 8 happy years of marriage!

Best

Jim

Anonymous said...

I discovered 3 weeks ago that my husband is involved with his optometrist. He forgot his wallet in the hotel where they used to meet, and the clerk man called to our home. I am in a big depression. 3 months ago, I found a note in my husband computer where she was telling him how much she was missing their long conversations. When I asked my husband about it he told that they were only friends, also she wrote a note to me and called me to tell me the same...I think the emotional abuse has been enough fo me. I am in shock and I am very sad...
Best regards,
White star...

Jim Sabin said...

Dear White Star -

I'm sorry to hear about the distress you are feeling. Your reaction is totally understandable in the context of a marriage.

I don't know whether there's any additional distress from the fact that the person your husband was involved with is a health care professional. My guess is that you would feel the same if the optometrist were someone he had met, rather than someone he had received care from.

I'm a "liberal" on most political and moral issues, but I'm "conservative" about ethical expectations for health professionals. Unlike, say, gynecology, optometry doesn't involve caring for a disrobed person, but it carries the same commitment to caring for the person as a patient and restraining other forms of involvement, like a sexual relationship.

I think of the obligations of the health professional as including consideration of the well being of those who are close to our patients. The injury you feel focuses on your husband's actions, but the optometrist's actions hurt the trust we're prepared to place in health professionals as well.

I hope your situation resolves itself well over time!

Best

Jim

Lost said...

I've been involved with my doctor for a couple of months now. There are a lot of factors which make the relationship wrong - mostly on his side: a huge age gap, his marriage & family, the fact that he's a doctor. He also knows my father, who is a fellow doctor, and the relationship started right when I practically committed suicide. It might be a stupid question, but did he take advantage? I am fully in my right mind and did not feel abused in any way, but I suppose psychology would show that there must be some part of me that was taken advantage of.

We started the relationship and after a few days, it dwindled. I've been reading some of the comments and it seems that they are all the same: at some point, the physician leaves, leaving the patient abandoned and used. Is this what they mean when they say that the relationship never works, and that it is self-serving (for the physician)? Thank you for any comments.

Jim Sabin said...

Dear Lost -

Thank you for your comments and for the important questions you raise.

The question of whether your physician "took advantage" of you is complicated in interesting ways. You report that you knew what you were doing - you were in your "right mind" and you "did not feel abused." From what you say, you weren't "tricked into the relationship" by promises or other duplicitous means. But if you had met the physician at a party and not as your caretaker, would you have been attracted to him and entered into a relationship? If the answer is "no," it would look like the physician took advantage of the aura (in psychological jargon, "transference") created by the role he was in.

But even if he in no way whatsoever "took advantage" of you, as I've argued in the posts I've done on this topic, medical ethics correctly proscribes physician-patient romantic and sexual relationships. There are two main reasons the prohibition is correct.

First, there is a substantial potential for harm to the patient. This doesn't mean that every patient is harmed every time a relationship occurs. But the risk is substantial. Given the basic Hippocratic teaching - "first, do no harm," ethical physicians will not put their patients at risk by entering into romantic relationships.

Second, much of the healing potential in the physician role comes from trust. In the course of medical care physicians may touch us physically in "intimate" ways and may probe our private thoughts and experiences in ways we do not allow others to do. If we can't trust our physicians to maintain proper boundaries, the whole profession suffers, even if the particular patient does not.

The pattern you describe, in which the patient ends up feeling "abandoned and used" is not unusual. We don't have the kind of data to tell us whether that is 10%, 50% or 90% of the relationships, but being hurt the way you describe is a significant risk, and should be enough to lead ethical physicians to control their impulses and not enter into romantic or sexual relationships with patients.

Given that the situation you describe began after a crisis in which you "practically committed suicide," you ought to have a clinician to work with who will focus on your health and well being, one piece of which is respecting professional boundaries. I hope you have been able to establish a clinical relationship of that kind!

Best

Jim

Lost said...

Thank you for your prompt reply, Dr MacDonald. If there's anything that breaches professional ethics, I suppose it's the fact that things are no longer the same between us; I can't imagine seeiing him again as a doctor. I've tried asking him if he'd rather have me see another specialist, so as to end our professional relationship, but he refused. The strange thing is that before, he seemed actually concerned about my well-being; but after getting into a relationship with him, he seemed to lose interest. Maybe I've stopped being "patient" and turned into some friend or partner. I do undderstand the potential harm that this may cause to the whole community; how can patients ever fully trust their physicians if patient-doctor relationships are allowed? To answer your question: the times I spent inside his clinic were times when we would tell each other stories; not really simple consults anymore. The latter parts, he was already opening up to me, which, if I've done my research correctly, should not be done by a doctor. I thought we just naturally treated each other differently, because he knows my father (a fellow doctor), and treated me differently. (Now that might be taking advantage, but it's a different story altogether.)

My doctor used to give me hugs back in his clinic, during my consultations with him. I thought this was just a kind gesture coming from someone who sees me differently. But looking back, it may have been different already, for my doctor.

Anonymous said...

Jim,

You seem to be pretty wise so I'd like to throw out my scenario. I have had the same ob/gyn for 14 years. He delivered 2 of my 3 kids and has been a fantastic doctor. He obviously knows a lot about me and has shared about his family over the years.

At a recent visit, I revealed that I was struggling at home and in my marriage because it related to the physical issue I was there about. He prescribed medicine and told me to call if it got worse. I mentioned, as I have in the past, that calling his office is a nightmare of an epic nature. He proceeded to give me his cell phone number. When I left the office, he didn't charge me for the visit. I asked a girlfriend about it and she said that phone number was not about medical care. I sent a friendly text to see if she was right and the response I got was personal, but not inappropriate. I had to go in for a follow up and the next encounter was awkward and fraught with mixed messages. Any input on this situation. Is this doctor crossing the line?

Jim Sabin said...

Dear (1) Lost and (2) Anonymous -

Thank you VERY much for your thoughtful comments, which both raise important issues about doctor-patient relationships.

Lost's comment that "I can't imagine seeing him again as a doctor" shows how we physicians can undermine the doctor-patient relationship and deprive our patients of the kind of clinical caretaking they deserve. Lost - your speculation that "maybe I've stopped being a 'patient' and turned into some friend or partner" could be correct. In medical education, we encourage skills at self-observation, so that physicians can ask themselves - "are improper motives and feelings entering in to what I'm doing, or thinking of doing?"

Both of you bring up the challenging issue of how physicians should handle the issue of self-disclosure. The guiding principle is that self-disclosure should (1) serve the interests of the patient, (2) not put burdens on the patient, and (3) observe "appropriate" discretion and propriety. Lost - your comment that your physician was "opening up to me" in a way that at least in retrospect doesn't feel right suggests that his self-disclosures didn't meet the three conditions I suggested. When I saw my own primary care physician about a musculoskeletal problem, his telling me about his experience with knee surgery was appropriate and useful. But if he had been going through a divorce, bringing that up would have been wrong. Like other human beings, we physicians need to ventilate our concerns and seek support, but that belongs in our circle of friends, or our own caretakers, and not with our patients.

Anonymous - your vignette is fascinating. There's nothing wrong in principle with giving a cell phone number. But something triggered your girlfriend's concern. Perhaps it was that your Ob/Gyn didn't charge for the visit. Maybe she thought he was treating the appointment like a date, not a medical visit. It was wise on your part to conduct a little experiment with your "friendly text." The response you got back was apparently ambiguous - "personal," perhaps not "medical," but not "inappropriate." But your visit, as you describe it, was uncomfortable.

Here are my thoughts re your question as to whether your doctor is "crossing the line." Your reaction, like Lost's reaction to her physician, suggests that the comfortable medical relationship has been disrupted. We're all capable of misunderstanding, so it's possible that he wasn't "crossing the line" and your discomfort reflects a misunderstanding on your part. But the thoughtfulness of your note, the fact that you enlisted a girlfriend to consult with, and the "scientific method" you used in sending the text message probe, suggests that you may well be perceiving your doctor sliding towards an inappropriate relationship.

Coming back to Lost's note - it isn't up to your doctor as to whether you see another specialist, it's up to you!

Again, thank you both for raising such important issues. And, insofar as your physicians may have moved into actions that violate the ethical precepts of our profession, I apologize to you on behalf of the profession.

Best

Jim

Anonymous said...

Thank you Dr Mc Donald for your answer...
It has been many months trying to fix my marriage, but it has been not an easy way. This female optometrist and my husband hurt me and all our love ones badly. The way she approached my husband was telling him about her sick kid, and the many nights without sleeping taking in care him! It is amazing that she had the time to call my husband to talk about it, and meet him to have sex crying in his arms! I think she is mentally sick because later my husband discovered that it happened many years ago and her kid is healthy. I am wondering where the father of her sick kid is? I asked my husband several times to leave me, and have a nice life with his optometrist because I really want their happiness, so he is free to go. I left my successful career as a petroleum engineer to follow and support him. He knows that I will be not too much time by myself because many people (men) are telling him how much fortune he has because I am beautiful, honest, very sweet and smart. Many of his friends tried to be close to me, and I never did anything against our relationship, so I cannot understand how in the world he had this affair with this ugly woman (physically and spiritually) He is the one that has to live the rest of his life embarrassed about it and not me! He does not want to talk about our divorce, and he still asking for forgiveness...
I started contacting my old classmates, taking training courses, and I am sending my CV to different oil companies. I am ready to start working again. I am ready to enjoy the life again! I learned to do not put my life in the hands of nobody!
Best regards and blessings Dr. Donald

Jim Sabin said...

Dear Anonymous -

Thank you for this follow up to your note on May 18.

I want to wish you good luck in putting your life back together!

Best

Jim

Anonymous said...

My dermatologist pursued me, started an affair, divorced his wife, hired me at his office, verbally abused me in front of staff and patients..... In Texas, is this malpractice or just really bad ethics and anger management?

Jim Sabin said...

Dear Anonymous

I'm sorry for the delay in responding - I'm still catching up on many things after the holidays.

With regard to your question - what you describe is unquestionably bad ethics. Hippocrates, who I quoted in my original post, would have reached the same conclusion 2500 years ago!

"Malpractice" is a legal term. A useful memory tool is "four Ds." A court will look to see if the physician Deviated from Duty thereby Directly causing Damage to the patient. A physician who initiated a sexual affair with a current patient would be vulnerable for the first two "Ds." The question would then hinge on whether those actions harmed the patient.

I wish you the best in the complicated and painful-sounding situation you've been part of.

Jim

Anonymous said...

Hi,

My Mother's doctor is kind of cute. What does the medical code of ethics say about dating your Mom's doctor?

Anonymous

Jim Sabin said...

Dear Anonymous -

Thank you for your question. To the best of my knowledge the code of ethics doesn't say anything directly about a doctor getting involved with a family member. But especially in psychiatry, and probably also in other areas of practice where the physician has an ongoing relationship with patients (primary care, OBGYN, etc), it would be a violation of professional ethics for the physician to date a close family member, for two main reasons. First, it could complicate treatment of the patient. Second, there could be an element of "power" in relation to the family member, since we often have intense feelings like dependency and gratitude towards those who care for our family members.

The ethical guidance is for the physician, not for the patient's family. You're free to be interested in dating the physician. But if the physician asked me for advice I'd say it would be unwise clinically and out of sync with the ethical teachings of the profession.

FYI, in the introductory course on medical ethics at Harvard Medical School we use a hypothetical case that imagines a male resident whose female patient wants to fix him up with her daughter, who is a medical student in town. We ask the students their views on the case. It evokes a lot of feeling. The dominant reaction the first year students have is in accord with what I said above. More than one young woman has said "I can imagine my grandmother/grandfather doing exactly the same thing!"

Thank you for the great question.

Best

Jim

Anonymous said...

My married sister's plastic surgeon called to give his condolences after the passing of our father. The doctor continued to call and fostered a personal friendship with her. He started to confide in her about his marital problems. They arranged to meet for dinner and entered into a 18 month affair. When my brother in-law discovered the affair, the doctor quickly abandoned her and started to make her look like the person who wanted the affair. My brother in-law filed an ethics complaint which is under investigation for over a year. I am the only person my sister will discuss the affair with, but not the only person that can see how the affair has affected her mentally. She is extremely depressed, filled with guilt and shame and has talked to me about ending her life. She refuses therapy, so I do the best I can to help her. Lately because of our conversations, I truly feel he took advantage of a vulnerable patient who was depressed over the loss of her father. She told me she had become dependent on him. Can you explain this dependence? She says she now knows how people follow a cult leader. Her pain is real and the result of a consensual affair with her doctor. He is not a mental health doctor; will he be held to the same standard?

Jim Sabin said...

Dear Anonymous -

Thank you for your comment and questions.

I can't explain the "dependence" your sister experienced as I don't know her or the details of her situation. But her comment about cults is significant. We turn to physicians for deeply personal reasons - whether illness or concerns about appearance and self image of the kind a plastic surgeon may consulted for. The reason professional ethics discourage sexual relationships with patients (including former patients) is that the "transference" to the physician can become a source of dependency or other forms of psychological injury. Your sister's comparison to a cult experience is insightful.

As you describe your sister's very distressed psychological state, I would support your effort to get her to add professional counseling to the important support you give her. Make it clear that it's not either/or - you will continue to be available as a caring sibling, but you can't be your sister's psychiatrist.

States are responsible for medical licensure and discipline, so I can't answer as to the standard the physician will be held to. The code of ethics of the American Society of Plastic Surgeons is vague - it prohibits "sexual misconduct," but doesn't define what the term means. For a psychiatrist, the fact that the affair was "consensual" would not shield the physician from sanction - in that specialty the ethics code says, in a straightforward way, that sexual relations with present or former patients is unethical.

Again, I encourage you to get your sister to see that distress that includes thoughts of suicide calls for professional counseling in addition to the help of a caring sibling.

Best

Jim

Anonymous said...

Jim,

I spoke to my sister about her feelings of dependency. She explained that emotionally he would control her life, he would tell her what excuse to use so she could meet him. He gave her a cell phone and called her at least 20 times a day. He would text her and tell her to get out of the house so he could talk to her. He would chastise her if she had sex with her husband and went as far as telling her to get into an argument with him if he wanted sex. She said she told herself every time they met that this would be the last time but she could not pull herself away from him, when he called she would meet him. When the affair was discovered the doctor gave her a different cell phone. She can't tell me why she continued the affair, although she thought she loved him. After my brother in-law contacted his wife the doctor taped a telephone call two weeks later wherein my sister said she missed his voice and his touch. He told her on the tape that he always said the affair was wrong and she should stop perusing him. He sent the tape to my brother in-law with an apology that said he knew it was wrong after the first night, but became fearful after my sister said she would contact his wife if he stopped the affair. He also said she is a wonderful person and eventually just got caught up in their relationship. Just to let you know, I'm 30, my sister is 40 and the doctor is 38. She has three children, the doctor has 4. Both have been married 15 years. I hope this gives you more insight into her thoughts. I will just add that she was extremely close to my father.

Jim Sabin said...

Dear Anonymoous -

Thank you for the further follow up. You clearly have a very close relationship with your "big sister." The details you give reinforce my recommendation that you continue to urge her to establish a counseling relationship. You've described her continuing grief at the loss of your father, and the very disturbing relationship that occurred after his death. A good counseling relationship could help her "process" what she's been through. Living with the shame, guilt, and suicidal thoughts that you've described is a painful state. Your sister sounds like a thoughtful person, and counseling could help.

With regard to the theme of sexual relationships between doctors and patients, you make clear just how vulnerable and needy your sister felt at the time, and how the physician could come to be, as she said, like a "cult" leader for her.

She's lucky to have a sibling who is so attentive and concerned!

Best

Jim

Anonymous said...

Hi, my GP is fairly young and around the same age as myself, our first consultation was somewhat of a medical emergency so was quite intense. I realised that I was attracted to the GP after this visit and decided to see a female GP as a result thereafter. However I was not getting very far with the medical problem and went back to the initial GP who I thought had been a good doctor.

I was a little confused at the second appointment that he seemed very annoyed and practically shouty and did not know if it was because I'd seen someone else or if he was having a bad day. He examined my lungs but then later looked at me when he sat down inappropriately though I could see him. I really do not know what went wrong during this visit.

I have since seen this GP a few times and he has improved the medical problem but my consultations always take longer than I think is necessary. On the second from last visit, the GP seemed to ask related questions about not being sexually active but about 4 times, which was quite uneccessary and one subtle comment that could be seen as flirty.

Though these actions may be questionable, I can sense there is a mutual attraction and that we like each others company although we do not divert from medical issues, as far as I know we are both single. I know there are ethical restrictions, I would not get involved while I was a patient, I think maybe the GP has overstepped the mark a couple of times described above but he has also I can see tried to maintain an over the top professional manner on my last visit that seemed quite cold even. I have not done anything to encourage any inappropriate behaviour as a patient and do not know what the GPs intentions are otherwise.

It does seem a shame if two single people are interested, then breaking the doctor-patient should allow freedom to pursue a romantic relationship, in which I realise you are open to hurt and questionable intentions as you would be if you met someone in a bar. In terms of the ethics debate, it could be a dilemma single GPs do face and miss out on finding happiness both for the doctor and patient, although I do understand the reasoning behind protecting patients and public trust.

The GP seems to be trying to maintain a professional distance in the last visit and it does leave me to decide if I should find another doctor in the long term where both parties can be completely objective .

Jim Sabin said...

Dear Anonymous -

Thank you for your thoughtful comment. Life and love are genuinely complicated!

It sounds as if the GP is following the professional precepts about how to relate to patients. Your own intuition - to switch your care to another physician when you found yourself attracted to him at the first appointment - was practical and wise. It's too bad that you weren't happy with the female physician you saw.

From the perspective of ethics, the situation for physician and patient are not symmetrical. Physicians have distinctive professional, obligations in relation to their patients. Patients have ordinary human obligations in relation to their physicians. Put most simply, as patients, ethics "allow" us to seek a romantic relationship with our physicians, but as physicians, ethics "forbid" our seeking romantic relationships with (in most specialties) current patients.

Whatever constitutes good luck for your situation, I wish it for you!

Best

Jim

Anonymous said...

I have seriously fallen in love with my obgyn. I think about him all the time to the point of being nauseous. We are both married and I don't want to give him up as a doctor because he is amazing. Should I tell him how I feel or just continue to feel this way in private. He rubs my arms gives short back rubs and hugs but has never been inappropriate. I don't know how he is with other patients am I looking to much into it?

Jim Sabin said...

Dear Anonymous -

Thank you for describing the difficult dilemma you're experiencing.

It sounds as if you may be experiencing what in psychiatry is called "transference" - idealization of your physician and constant preoccupation with him. In psychiatric treatment those feelings would be used in the treatment as a source of insight into the problems the patient has presented with. But if the feelings persisted with such intensity that the patient was unable to benefit from the treatment process, the psychiatrist might refer the patient to another therapist.

I can't give you advice about what to do regarding your ob/gyn care, but I can quote from the ob/gyn code of ethics: "Sexual misconduct on the part of the obstetrician-gynecologist is an abuse of professional power and a violation of patient trust. Sexual contact or a romantic relationship between a physician and a current patient is always unethical." It's not clear that the profession would regard "back rubs and hugs" as part of "appropriate" care.

Given how intense a preoccupation you are experiencing, I suggest that you discuss the situation with a friend or family member who you trust and respect, or with a counselor. It's almost always helpful to get an objective perspective on situations that are causing difficulty for us.

Best

Jim

Anonymous said...

Oh boy... Last year my husband of 2 years abruptly abandoned me while I was having treatment for a serious medical condition. I was having severe anxiety. During a visit at endocrinology office the advanced nurse practitioner suggested that he knew the best treatment for my anxiety. He gave me his cell and told me to call him later. I called him and he asked me over to his house. I showed up and he pulled out marijuana and told me that this would be the best treatment to get me to relax. I had never smoked marijuana before but I agreed to try it. I got high and we had consensual.... Although foggy, sex. We had a few more interactions like that in the following 3 months.

Fast forward a year later.... I attended counseling to work through the abandonment of my husband and I find myself angry that this healthcare provider took advantage of my vulnerable state.

I am out right embarrassed that it happened. I am an educated professional woman and acted completely out of character.

Aren't our health care providers supposed to help us prevent self destructive behavior during times of crisis? Now that I'm healthy I can't believe my provider brought me to his house to get me high and have sex with me. I think I'm going to have to go to counseling just for that!

Sorry... I probably don't have a question. I had to vent.

Jim Sabin said...

Dear Anonymous -

The incident(s) you describe represent flagrantly unethical professional, and ordinary human, behavior on the part of the nurse practitioner. He apparently recognized a vulnerable person in a crisis state and exploited you.

Please don't be too hard on yourself. You're clearly an intelligent and ordinarily clear-minded person who was in a very distraught state. Good that you've used counseling to learn from the experience with your husband and its aftermath.

It's totally up to you as to whether you take any action about the nurse practitioner. But if someone in my medical office had been acting that way I would have been horrified and certainly would have wanted to know.

Thank you for your comment. I wish you good luck and good health in the future!

Best

Jim

Crystal said...

I just wanted to empathize with the females on here that have fallen for their OBGYN. My doctor happens to be a gynecological oncologist. He was my aunts oncologist and then I am coinicidentally referred to him. And no it's not a small town either. The first few visits with him were a blur from the realization of a cancer diagnosis and the major surgery that was to follow. I did however notice that he seemed to be only about 10 years older than me (me being 29) and he is attractive yet no wedding ring. Then right before being wheeled into the operating room I'm crying because I'm scared to death and a nurse says to me, "you'll be fine, he's a great doctor. He's not too hard on the eyes either is he!" A month after the surgery I came to realize that I was attracted TO him. At first - I immediately felt perverted and shunned the idea. But now I find myself thinking about it more and more. Now that I've realized this attraction I feel toward him it makes these follow up office visits incredibly stressful. I am a nervous wreck. My heart races and I even start perspiring. Afterward I find myself contemplating a way that I could convey to him that I find him attractive without outright saying it and embarrasing myself. Then my thought process gets cut off by the rational part of my brain telling me to leave it alone. He could be married and lost the ring, he may be engaged, or he may not even be heterosexual. And really, what would someone like him want with someone like me anyway? Ontop of that an oncologist having personal interest in someone that has even a remote chance of cancer recurrence is kind of contradictory or taboo In my opinion. I did recently give him a hug and thanked him for the surgery he did. It was awkward. I hugged him by his hips (he's tall) and went inside his lab coat when I did it. And I may have surprised or startled him. I think a part of me may have done that intentionally - I'm not sure. I immediately felt stupid for doing that. And speed walked out of the office. I'm just really struggling here especially when I read stories where things actually worked out once the patient was no longer a patient and they developed a healthy intimate relationship. Now that I have made this comment too long, I would love to hear any thoughts or adivce or suggestions you or anyone else may have. Thank you for your time.

Jim Sabin said...

Dear Crystal

Thank you for your thoughtful and meaningful comment.

For situations like yours it's useful to distinguish between the medical ethics considerations that apply to the physician and the "human ethics" considerations that apply to the patient.

It's easy to understand how any of us could be attracted to a person a) we depend on for our health and well-being, b) who has had highly personal contact with us through the physical examination(s) and clinical conversations, and who, apart from these factors, is c) highly attractive in conventional terms. Factors a) and b) invite emotional reactions that are independent of ordinary forces of attraction, whereas c) is one of the factors that underlies the mystery of "chemistry."

In terms of the "transference" involved with a) and b), there's a hilarious scene in Woody Allen's film "Annie Hall." Annie has been rhapsodizing about how exciting and attractive her therapist is, but when she and Woody Allen meet him he is, in conventional terms, highly unattractive. This latter fact doesn't apply to your gynecologist, but the power of "transference" can be at work for any of us in a medical situation.

The bottom line for me is that you should not be hard on yourself, as in labelling yourself as a "pervert." You've been through a lot between a cancer scare and surgery. I hope you are discussing your emotional reactions, including attraction to the surgeon, with reliable and trusted friends.

We physicians should be well educated about not exploiting the emotional reactions of our patients. I recall one of my teachers from my psychiatry residency describing a situation like yours. He said to the patient - "Thank you for your kind comments. There are lots of attractive men in the world for you to be interested in, but only one psychiatrist who knows you and your treatment well. You need me to stay in that role..."

A gynecological oncologist is likely to have long term contact with his patients. Even if no further treatment is needed, there are usually periodic followups. Your physician, like all of his colleagues, needs to find ways to make you comfortable in the office, and to convey that he likes and respects you, but is not seeking to develop a non-medical relationship - not because of any personal limitations on your part, but because acting that way is part of our responsibility as physicians!

Again, thank you for your honest and important comments. I'm sure they will be useful to others.

Best

Jim

Anonymous said...

Faced with the reality and potential of this manner of relationship, my research led me to this blog.

A bit of background: my spouse and I have been experiencing problems for some time and chose to seek counseling. After a number a months, it has become clear we will not be staying together. During this time, we've met with our counselor as both couple and individually. Over the course of counseling, the therapist (female) and I have developed a friendship although have never gone further with it.

During the past month, there has been a subtle shift in our friendship and it has become evident feelings exist beyond simple friendship- for both of us. With the termination of our business relationship near at hand, the subject of our relationship was broached; it's apparent we feel much the same way about one another..

Too, the subject of ethics has been discussed at length and- as much as two human beings in such a situation can be- circumspection has been the order of the day.

The subject of transference, harm to the patient, position of power and the myriad other pitfalls of such situations has been discussed at length... Yet neither of us have come to any concrete solutions or answers.

We are both middle age and with this, have recognized the impossibly imminent shade of gray which creeps into our decision making as we've grown older. Things we may have never considered in the past seem not so impossible at this point in our lives. Mortality, obviously, colors our thinking.

The subject of abandonment, hurt, loss, pain, etc., seems like the slippery slope, where does this end? Are not these the emotions we might possibly feel with any relationship undertaken and later severed? Are we to simply put our heads in the sand?

For obvious reasons, I've been discharged from her care and neither of us are certain of our next steps- while understanding we want very much to remain in contact.

Thoughts?

Jim Sabin said...

Dear Anonymous -

I'm flying to England tomorrow morning so won't write at length. But your thoughtful comment raises important and challenging questions.

I distinguish between the ethical context for the client/patient and the ethical context for the therapist. In our role as client/patient we should be attentive to "human ethics." You've met someone who you find appealing and should assess the situation the way you would had you met in other circumstances. How would a relationship affect your former spouse? How much do you trust your feelings? I don't see any distinctive ethical considerations arising from the fact of being a client/patient. But don't underestimate the power of "transference" and "counter-transference"!

For the therapist there are different considerations. The mental health professions have clear guidance on relationships between clinicians and former clients/patients. But apart from the ethical precepts formulated by the professions for their own conduct, the kinds of questions you and the therapist have discussed could well be looked at with a third party consultant, to get an "objective outsider's" view.

Thank you for raising these important questions. If you have further thoughts I would welcome then, and would respond on my return.

Best

Jim

Anonymous said...

I am so relieved to find your blog here. I have been wrestling with my feelings over an affair I had with my chiropractor that just ended. We are both married and I always assumed because it was consensual I had no reason (or right) to complain if things went awry. I still feel that way at times, but the psychologist I am seeing thinks differently and is urging me to file a complaint. In fact I believe she may have filed something already because when I look up his info on the Consumer Affairs website, it shows a recent accusation has been filed against him.

I am nervous now because I don't want my husband to find out or the doctor to trace it back me. I feel a tremendous amount of guilt over this, but after reading your responses to others and looking at the situation objectively, I realize that it is ultimately up to the medical professional to exhibit restraint and good judgment right from the start.

Your example of whether a patient would have submitted to a relationship outside of doctor/patient setting really hit home with me because I can honestly say that "no", it would have never come up, because the biggest part of my attraction to him was his nuturing, caring behavior, coupled with the physical contact that had to happen during the course of each visit. It was all very seductive and subtle and it made me feel wonderful and desired at the time. Now I feel used and ashamed for my participation and wonder how many other lonely female patients have been affected. I think this is the place my psychologist is coming from.

I'm not sure what I hope to accomplish by posting this--validation that I did not purposfully pursue this doctor or lead him on? (Which I did not, btw). At the very least, I feel like it may help others who feel ambiguous about their participation in a doctor/patient affair and see the emotional and mental turmoil it causes a patient.

I am hurt and confused right now and wish this never happened.

Jim Sabin said...

Dear Anonymous

Thank you for your very thoughtful comment. I am sorry about the painful experience you've had, but glad that you a) are working with a therapist and b) found my blog post helpful.

Your analysis of the way caring and nurturing, combined with physical contact, can elicit what in psychiatry would be called a romantic "transference" will be very useful to other readers. In my own specialty (psychiatry) the intimate conversation in a very private space can have a similar effect.

You are 100% correct that the clinician is responsible for maintaining the right combination of caring and steadfast professionalism.

Again, thank you for your very thoughtful comments. I hope you find peace in relation to a relationship that your chiropracter should not have allowed to happen.

Best

Jim

Anonymous said...

Jim- thanks for your blog. I would like to present a scenario which recently happen. A physician was treating my father in law and mother in law. The physician entered into a sexually relationship with the patients daughter which is/was my wife. Needless to say the affair caused tremendous pain. During the affair the physician continued to treat my mother in law. For obvious reason a divorce occurred and two days after the divorce the physician married my ex-wife. After the marriage of said physician and my ex-wife he was introduced to my children and in the patients house ( recall- patient was is patient and now his mother in law and patient). It's obvious that the physician used the physician - patient relationship to exploit a sexual encounter with patients daughter for personal gratification. What happen to " purity", " holiness", and " for the benefit of the sick".?

Jim Sabin said...

Dear Anonymous -
I'm very sorry for the painful experiences you describe. Whatever happens in the future in the relationship between the physician and your ex-wife and his relationship with his patient/your ex-mother-in-law, the facts you present represent a clear violation of the code of ethics for every specialty. I refer to the future because sometimes these relationships appear to work out well for the participants, but that does not invalidate the ethical precepts of the medical profession. Those precepts derive from the ancient teachings about what was seen as the "sacred" responsibilities of physicians. Even in a secular age, I like to use terms like those you cited.
I want to wish you the best for your own future. Thank you for your comment.
Best
Jim