Wednesday, November 25, 2009

Doctor-Patient Sex: Why is it Unethical?

Earlier today I responded to the following anonymous response to a post I wrote in April about doctor-patient sex:
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.

The comment got me thinking. To the best of my knowledge, every medical specialty in all of the countries whose medical ethics I'm familiar with finds doctor-patient sex unethical. But as the questioner noted, it's not clear what the basis of that ethical condemnation is.

I did some on line browsing in the literature and came upon an excellent article - "Arguments for Zero Tolerance of Sexual Contact between Doctors and Patients" - by R.M. Cullen, a GP in New Zealand.

Dr. Cullen examines four common justifications of the zero tolerance view of doctor-patient sex and finds them all inadequate to the task:

  1. Sex with patients is always harmful. Cullen points out that the evidence base for this conclusion is skimpy. There are no surveys of large numbers of patients who have had sex with their physicians to see how many have been harmed. What we have is powerful case reports of individual situations that were harmful to specific individuals. These don't prove that doctor-patient sex is inevitably harmful.

  2. Sex with patients always violates the principles that define an ethical sexual relationship: trust, equitable power balance, and consent. Cullen quotes a position paper by the College of Physicians of Ontario that concludes that because of the inevitable power imbalance between physician and patient, valid consent is never possible. But here too it is possible to imagine doctor-patient relationships that do not violate the principles.

  3. Sex with patients is always inconsistent with the virtues that characterize the ethical physician. Here Cullen cites an argument that to be ethical a physician must be self-effacing and self-sacrificing, and that these virtues rule out deriving sexual satisfaction with a patient. Once again Cullen concludes that we can imagine circumstances in which a self-effacing and self-sacrificing doctor falls in love with a patient and is loved in return.

  4. Finally, Cullen considers the argument that the intrinsic nature of medicine may forbid sexual contact with patients on an a priori basis. Edmund Pelligrino makes the strongest argument of this kind, in "Toward a Reconstruction of Medical Morality" and elsewhere. Pellegrino argues that three phenomena – the fact of illness, the act of profession, and the process of care – if understood properly, provide a coherent basis for professional ethics, including the prohibition of doctor-patent sex. But here, too, Cullen finds it possible to postulate examples that could evade this perspective.

Cullen's own argument for the zero tolerance position is simple and practical:

It first attempts establish that, as a matter of policy, sexual contact between doctors and patients ought to be prohibited. Then, [it asserts] that doctors have a moral obligation to comply with such a prohibition. If this is true then it follows, as a matter of definition, that doctors who have sexual contact with patients have behaved immorally.

[This] counterfactual argument may be summarised as:

Proposition. If sexual contact between doctors and patients were allowed then there would be unacceptable consequences.

Conclusion. Sexual contact between doctors and patients should not be allowed.

Cullen argues - in my view correctly - that it is not necessary to prove that every instance of doctor-patient sex will be harmful, contrary to principles and virtues, or inconsistent with the fundamental nature of medicine, to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero tolerance ethical stance based on (a) the potential for harm to the patient with (b) no offsetting potential benefits for the patient, combined with (c) the inevitable harm to trust in the medical profession itself, and via that loss of trust, loss of healing capacity.

Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.


Jim Sabin said...

I received a comment along with a request not to publish it. The commentator described an interaction with a clinician that did not end in a consumated sexual relationship, but in which the clinician, over time, conveyed interest in having such a relationship. The writer of the comment reports being left with feelings of guilt, dismay, and isolation.

As Dr. Cullen pointed out in the article I cited, we don't know how many patients who experience an actual sexual relationship with or sexual advances from a clinician are harmed, but we know from situations like that of the anonymous commentator that some experience significant harm. Since we human beings tend to put trust in those we turn to for care, there's the potential for feeling betrayed, violated, and perhaps guilty, as if it's "our fault" that the clinician has violated professional expectations.

I hope the writer of the anonymous comment can receive good counseling to get past the painful state described in the comment.

Anonymous said...

I was the patient in a doctor/patient relationship which included sexualizing conduct towards me by a doctor and this had devastating consequences for me.
On my 2nd visit to this dr's office, he asked me what I was doing for the weekend and stated he was doing nothing, then followed me into the hallway outside his office, came up behind me and slipped his arm around my waist. The effect of this was to sexualize our relationship. I know this because I experienced that effect firsthand. Being single and finding him attractive, I enjoyed his interest in me. I found myself desiring further closeness and having feelings towards him. When I found out he was married, I felt confused by his actions, unclear about his motivations, and guilty about my own.
I carried this conflict within me throughout treatment, which lasted a year until it was terminated by me for two reasons: 1) I felt the dynamic of unrequited love between us was not healthy; and 2) this doctor refused to own any participation or responsibility in the co-creation of that dynamic when I tried to discuss this honestly with him.
Over the course of my treatment, I was motivated to continue treatment as it provided me with relief from chronic pain, which no other practitioners had been able to accomplish.
I now recognize that this doctor abused his power and exploited my vulnerability and trust. Not only was I dependent on him for relief of pain, I was also vulnerable to him regarding other key survival issues, as his input had a bearing on my finances in that his input to my disability insurance carrier had the potential to terminate my coverage. This did happen when he filled out a form incorrectly and projected my ability to return to work inaccurately. After I asked him to, he addressed this & my benefits were reinstated.
Various opportunities were afforded to him, by virtue of his doctor role, which would not have been accorded to him otherwise: high levels of intimacy and trust; frequent, regular visits; and repeated physical proximity.
When I confronted him about his sexualizing actions, he stated, "I would never get involved with a patient," as if that statement absolved him of any further responsibility. I terminated treatment the next day.
When I told him later over e-mail that my heart was broken and I felt the loss of all my modesty and dignity, that I was having trouble sleeping and asked him to help me find a doctor to prescribe me Ativan, as the doctors I would normally have gone to were his business partner and that person's brother, he told me I should be able to find a doctor in my own community, not to worry about my pride, and suggested I put an icepack on my head at bedtime for insomnia.
I was left utterly devastated. I felt humiliated, exploited, betrayed, rejected and abandoned - dismissed without any compassion or respect.
Because he never actually had sex with me and I admitted my own feelings for him, I would anticipate only further drain and pain for me should I report this. I have no wish to see his career destroyed.
But the way he handled his relationship with me was irresponsible and disrespectful, and his treatment of me emotionally was incredibly callous in the end. Much of the progress in resolving my pain and disability was lost. I could barely eat or sleep for weeks. I felt no joy in living and felt suicidal. After six months of regular therapy I still feel the effects of what occurred between us. I have been left to assume all responsibility in the situation - his AND mine - and all costs of addressing the consequences.

Jim Sabin said...

Dear Anonymous -

Thank you for this very full comment. You bring out a very important clinical and ethical point. You did not have an overt sexual relationship with the doctor, but you felt confused, guilty, and distressed by the experience. It's important for physicians to understand the degree of trust we patients place in them (I say "we" because I'm a patient as well as a physician). Deviating from a caring professional relationship, quite apart from whether or not there is any form of actual sex, can be emotionally harmful, as you describe so clearly.

In my view the fact that the doctor was married does not change the ethics of his responsibilities towards you. His responsibility is to comport himself in accord with the ethical requirements of the profession. It would have been just as much of a deviation from professional ethics if he had been single.

I hope the therapy you sought out will ultimately help you get fully out of the depressed state your experience left you in.

Again, thank you for sharing this rich and educative description of what you've been through. I'm sorry for what you've experienced. Best wishes for the future!


Jim Sabin said...

I received a further communication from the anonymous commentator I responded to on January 30. While this second communication did not include a request that I not publish it I was uncertain as to whether or not "Athena" (the pen name the commentator selected) wanted the comment to be posted, so I've taken the safer course of quoting a segment that has no personally identifying material, and summerizing the rest. Here's what I feel comfortable quoting:

"Dear Jim, thank you for your compassionate reply, and for your courage and openness in establishing and moderating this forum for discussion of the sensitive issues relating to doctor-patient sexual misconduct. I feel that raising awareness around these issues, on the part of both patients and doctors, is essential to facilitating the elimination of doctor-patient sexual abuse. After my own experiences in this area, some of which I related above, I have felt the need to become more informed so as to better understand what actually occurred and how it was allowed to happen. I see that the potential for abuse arises in every sector of our society where the balance of power is unequal. People who are granted power and authority sometimes disregard the responsibilities inherent to their positions and although they have been trusted to handle their power wisely, they often fail to do so. Politicians, judges, clergy, employers, parents, doctors – no one is immune. For abuse to be eliminated, doctors and patients need to be informed that they are not exempt from this phenomenon. In the doctor/patient sector this has many ramifications, some of which life experience has made me intimately aware of. At the heart of this matter is a matter of heart – and spine. For change to be effected in this area we need not only increased compassion and understanding, but also the willingness to stand up for actions that need to be taken to eliminate doctor-patient sexual abuse. I believe it is the responsibility of those who are aware of this abuse (doctors and patients alike) to begin to speak of it more openly, to assist others through sharing of insights and experiences, and to work effectively to facilitate necessary changes..."

"Athena" goes on to describe an experience that was suggestive and for which I couldn't discern a legitimate medical objective. If there was such an objective the physician did not explain it and did not ask for permission to carry it out, as medical students are taught to do.

Some very routine medical procedures such as pelvic, breast and rectal examinations are very intimate. But done (a) with clear explanation of the purpose, (b) in a professional manner, which may include having a chaperone in the room, and (c) only with permission, the procedures are generally well tolerated and not a source of trauma.

Hearing about how our patients interpret and react to our actions as physicians is an important component of medical education - and not just for medical students. Human nature is immensely varied - that's part of what makes our species so interesting! We can't assume we know what the impact of our actions will be.

"Athena" - your thoughtful comments represent just the kind of dialogue I hope these posts might lead to.



Anonymous said...

After two operations, infertility treatments and two babies my OB suddenly informed me that our relationship was now a sexual one albiet covertly during a bizarre sexual lecture. In denial I went back one more time, and he did something inappropriate during an exam. I started obsessing about going back and had to seek the help of a psychologist. Luckily I ended up with a counselor who got to the root of my issue quickly.

I too assumed all guilt for the incident. That's the kind of person I am and perhaps why I was selected for the "special treatment".

A year later it still crosses my mind daily. I often think about dropping his wife a note but I would never report the issue otherwise.

Jim Sabin said...

Dear Anonymous -

First, I apologize to you on behalf of the medical profession for your physician's unethical conduct.

You are very insightful in speculating that he may have mistreated you as he did because he sensed that you were someone who respected physicians and would see yourself as responsible for anything inappropriate that happened between you. Good that you had the wisdom to seek out counseling, and had the good fortune to find a counselor who was able to help you!

Informing his professional society would seem more desirable than informing his wife. For all we know they might have an "open marriage," and she would not regard his making advances to another woman as a violation of their mutual commitment. But his making sexual advances to you is a strong violation of professional ethics, and professions are supposed to monitor themselves.

Thank you for your constructive comment!



Anonymous said...

I have a completely different point of view on this matter. If a Dr. and patient engage in a sexual relationship and the patient consents to it I see nothing wrong with it.What upsets me about this kind of situation is that the patient can come back at the Dr. if she does not get her way any longer. If she allows the relationship to continue and then asks for something from the Dr. like an increase in medication and is denied, she then turns this Dr. into the state.She saves all information about the relationship including photos,DNA etc. then after a year, goes to the state and files a complaint against the DR. This patient difinately planned this,go after the Dr. when she was no longer getting what she wanted from the Dr. When someone saves all the evidence of sexual relations between them, this not a patient who was being used by the Dr. This patient kept all contact between the two of them so she could go after the Dr. at a later time. Why would she wait a year and save everything if she was not looking to gain from this situation? If you don't want anything to do with your Dr. then advise them so and go to another one. You have choices and you are also reponsible for your actions and care. I don't believe that the Dr. should be the one that loses his or her license due to the patient wanting financial gain or just plain revenge against the Dr.Walk out of the office and find another physician, it's that simple. I don't not have any simpathy for any patient that allows a relationship to begin with their health care provider. The only ones I have simpathy for is for a patient that has mental problems and is seeing a therapist to help with their mental problems.

Jim Sabin said...

Dear Anonymous -

Thank you for sharing your thoughts.

Here's my take on the situation you imagine: (1) A patient isn't doing anything morally "wrong" in entering a consensual relationship with a doctor. Doing so may reflect bad judgment, but it's not a moral fault. (2) Especially for psychiatrists, but for all physicians, it's a violation of medical ethics to conduct a sexual relationship with a current patient. So even if the relationship is 100% consensual and the patient is mature and able to make a thoughtful judgment, the physician has violated professional standards. (3) In other words, the ethical situation is "asymmetrical." The physician commits an ethical violation and the patient has not. (4) In the scenario you imagine, in which the patient is scheming against the physician, the patient has committed unethical actions by being duplicitous and manipulative.