Ethics case study
Should doctors treat their relatives?
This is the 21st in a series of case studies with commentaries by the Ethics and Human Rights Committee and the newly established Center for Ethics and Professionalism. The series uses hypothetical cases to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.
A 73-year-old woman with a history of hypertension, prior deep vein thrombosis, gout and degenerative arthritis calls her son, a physician, seeking medical advice.
"My physician is on vacation and my gout is acting up. I've used ibuprofen in the past and it isn't helping that much. Dr. Smith (her primary care physician) had prescribed another medicine that worked great. I think it was colchicine," she states.
Her son suggests she call the physician covering for Dr. Smith to discuss her situation and, if appropriate, obtain a prescription to renew her medication. She insists her son call the prescription in since "you went to medical school and know my situation better than some doctor on call."
He reluctantly calls in the renewal prescription. But he insists she follow-up with someone else as soon as possible. Fortunately, she is seeing her orthopedic surgeon in two days for her arthritis. "He doesn't know anything about gout," she replies, but agrees to allow him to look at her foot.
Later, she calls her son at home. "Well, you were wrong. It wasn't gout, but some sort of cellulitis and now I'm on two different antibiotics." She also insists her son discuss the sequence of events with Dr. Smith once she has returned from vacation.
Most physicians periodically provide medical care to their family members and significant others. (1-3) Some provide care to friends, employees and even themselves. Good reasons probably motivate these practices, and often no apparent difficulties arise. In some instances, however, there may be significant problems, especially if substandard care is provided. What is the nature of the patient-physician relationship in these instances and how is it affected?
The scenarios range from one doctor who performs an ear exam on her five-year-old son to determine whether he has otitis to another who does elective abdominal surgery on his wife. These situations occur for several reasons: Family members commonly request care from doctors who are related to them. (3) Physicians want to be available to their families, and they may feel obliged to offer their clinical expertise. Physicians may be embarrassed when their family members bother a colleague for what appears to be a simple problem, or they may intervene in the care of a family member because they disagree with that person's care provider. (4) And finally, it is often more convenient, or less expensive, for the physician family member to provide a service rather than for another doctor to be consulted. (1)
Many medical societies have policies on whether doctors should treat their families and significant others. For example, the College's "Ethics Manual" strongly discourages, but does not prohibit, physicians from treating family members, limiting such situations to those of necessity and cautioning that the patient be transferred to the care of another physician as soon as practical. (5) The AMA has a similar position regarding immediate family members. It adds that there are situations in which family members can provide routine care for short-term, "minor" problems. (6) No examples are cited, however, and this exception could swallow the rule. The AMA does specify that doctors should write prescriptions for controlled substances for themselves or immediate family members only in emergencies. (6) And in its position, the Canadian Medical Association says that treatment of family members should be limited to minor or emergency care or instances when another physician is not available. (7)
John La Puma, FACP, and E. Rush Priest, MD, pose a series of questions doctors should ask themselves when they are considering providing care for family members. They believe that individual physicians, arriving at personal answers to these questions will make appropriate decisions about care. (8) While these questions are well directed, caring for family members is not only a personal issue, but also one the profession should acknowledge and manage.
Several problems can arise when physicians care for their relatives. When the patient is a relatives, the informal nature of the situation may result in compromised care at any of the different steps in the clinical encounter: history taking, physical examination, diagnosis, treatment and follow-up.
Medical histories in these circumstances are often incomplete or assumed. Physicians may find it difficult to ask family members sensitive questions about drug use, sexual practices or other highly personal issues; alternatively, patients may be uncomfortable disclosing this information to a relative.
Physicians may omit or abbreviate physical exams performed on family members, or they may go beyond their area of expertise. In some cases, the relative lives far away and cannot easily be seen by the physician; in other cases, the physician performs the examination without the proper instruments. Additionally, the unease caused by physical intimacy may distract a doctor who needs to probe a parent's abdomen or axilla. Performing a mental status exam on a close relative may be even more difficult than examining the relative's body.
Some have argued that treating family members and other intimates is unwise because emotional involvement interferes with a physician's ability to be objective. (2) Such a loss of objectivity can affect diagnostic work-ups. To exclude all possibility of disease, some physicians obtain more tests on relatives than might be done in similar cases for other patients. Conversely, other doctors are less likely to recommend an invasive procedure that could be painful for a relative.
Diagnostic reasoning may also be faulty. For example, physicians might be unwilling to consider a diagnosis of cancer in their spouses. And physicians may alter treatment plans unwisely when they shorten therapies to spare their relatives a hospital visit.
Confusion in what should be a patient-physician relationship may influence the doctor to be particularly informal, and this too can compromise care. Physicians may fail to record their encounters, so there may be no documentation and no chart to consult. (1) In sum, in the clinical treatment of a family member, or intimate other, doctors are prone to omissions, abbreviations and informalities, which compromise care and can harm patients.
Physicians' professional relationships with their patients are based on fiduciary responsibility. Family relationships, by contrast, are based on love. Because a clinical encounter with a family member is not a typical patient-doctor relationship, physicians caring for family members may tend to ignore standard guidelines, such as respecting a patient's right to decide about treatment, informing the patient about the risks and benefits of treatment and the plausible alternatives, telling patients the truth and respecting confidentiality. A doctor might withhold the truth regarding a diagnosis from a parent, when she would tell the truth if the patient was not related to her. Another doctor might breach the confidentiality of a patient who is a relative. William B. Spaulding, MD, cites the case of a surgeon who told a newspaper reporter about a patient he had operated on; the patient was a relative who had not given him permission to discuss her case. (9)
The care delivered by a physician family member may be minor: an endometrial biopsy, a prescription for a diuretic or the confirmation of a presumed diagnosis as illustrated in our case study. Usually, these acts will not lead to bad physical outcomes. But even simple cases raise potential problems. In this case, which was not an emergency, the physician/son should have stuck by his initial advice that his mother seek care from the covering physician.
How should the profession determine which type of care is ethically and medically acceptable? The most defensible situations are those in which doctors can quickly act within their area of expertise to solve an immediate problem that does not require new medical evaluation. For example, if someone on a trip loses luggage that contains medications, it would seem appropriate for a physician-family member who is on the trip to refill the medications. Slightly less defensible is the situation in which a family member presents with complaints of a simple problem that is identical to a previously treated problem. This person knows the treatment needed, and merely wants to avoid the inconvenience of visiting another doctor. These first two situations, in which the physician-relative is simply "filling in" until the patient's primary doctor is available, seem the most acceptable. However, as our case study illustrates, avoiding inconvenience for a family member can result in mismanagement and a potentially serious negative outcome.
Less clear is caring for the family member with a new medical problem. If the problem is relatively simple, the services required might be as minor as performing a limited physical exam or prescribing some drugs. However, if the new medical problem is complex, it is harder to justify delivering the care unless the problem is in one's area of expertise, the care required is restricted to minor services or, especially, if no one else is available to deliver the care. Finally, there are services that seem unacceptable to offer to any intimate or family member, such as acting as the person's primary medical provider, performing major surgery or acting as the person's individual family psychotherapist.
If it becomes necessary to treat a family member, physicians should consider the following:
- In deciding whether a patient is too much of an intimate to treat, the type of relationship is less important than one's emotional closeness. A close friend may be as much of an intimate as one's sibling, child, parent or significant other. At issue is whether one's closeness to the individual obscures the physician's ability to be objective. If this is unclear, one should consult with another physician.
- Physicians should remind family members that they can provide access to the system and advocacy without directly treating the patient. Many family members prefer advice and referral to another trusted physician over a relative's hands-on care but may not be willing to say so.
- Physicians must consider whether the service required falls within their area of expertise. If a request is significantly outside a physician's professional specialty area, the likelihood of a misdiagnosis or incorrect treatment increases.
- Physicians contemplating treating family members should carefully assess the limitations of the medical setting. Whenever possible, care should be delivered in the standard practice environment. If the setting is unusual, physicians must be sure that this alternative environment does not compromise quality.
- When care is given to family members, physicians should keep records and communicate with the individual's primary physician. Notes on the care of a family member should be accessible and shared with other caregivers. When there is a bad outcome, cases involving family members are appropriate for discussion at morbidity and mortality rounds and other similar forums.
Physicians will always encounter requests for care from their own family members and significant others. We need to acknowledge that in some cases answering these requests directly can result in strained family relations, as well as compromised medical care and physician-patient relationships. Often, the most caring and professional response one can offer is to help the person negotiate the health care system, leaving direct medical care to others. By refusing to be your brother's doctor, but assuring him that you will advise him and make referrals, you may most rigorously fulfill the commandment to be your brother's keeper.
Acknowledgments: The Ethics and Human Rights Committee would like to thank Richard J. Carroll, ACP-ASIM Member, author of the case history; James A. Tulsky, ACP-ASIM Member, Miriam Shuchman, MD; Lois Snyder, JD; and Dr. Carroll, authors of the commentary.
1. Dusdieker L, Murph J, Dungy C, Murph W. Who provides health care to the children of physicians? Amer J Dis Chil. 1991;145:391-2.
2. Gartrell NK, Milliken N, Goodson WH, Thiemann S, Lo B. Physician-patient sexual contact: prevalence and problems. West J Med. 1992;157:139-43.
3. La Puma J, Stocking CB, LaVoie D, Darling CA. When physicians treat members of their own families. Practices in a community hospital. N Engl J Med. 1991;325:1290-4.
4. McSherry J. Long-distance meddling: do MDs really know what's best for their children? Can Med Assoc J. 1988;139:420-2.
5. "American College of Physicians Ethics Manual," fourth ed. Ann Intern Med. 1998;128:576-594.
6. American Medical Association. Code of medical ethics: Current opinions. 1996-97.
7. Code of Ethics of the Canadian Medical Association. Can Med Ass J. 1996; 155:1176A-1176B.
8. La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA. 1992;267:1810-2.
9. Spaulding WB. Should you operate on your own mother? The Pharos. 1992;summer:23-6.
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