How to practice within ethical boundaries

From the June 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Ingrid Palmer

PHILADELPHIA—When it comes to exchanging gifts and having sexual relationships with patients, physicians should apply one simple rule of thumb: Do not use your position to gain an advantage that is not available to others.

That was the advice of Lee J. Dunn Jr., JD, a health care attorney in Boston who spoke about physicians' ethical conduct at an Annual Session course, "Law and Ethics: Boundary Violations." Using your influence as a physician to gain an advantage of any nature, he said, violates boundaries between yourself and your patients.

Gifts

"In general, accepting reasonable gifts to show appreciation or thanks is OK," said Mr. Dunn. (He does not recommend accepting expensive gifts like crystal, however.) He said to refuse a gift "when you think the patient is doing it for other reasons," for instance, as a come-on.

It is sometimes acceptable for psychiatrists to give patients small gifts to celebrate milestones. Giving gifts of minimal value may also help establish therapeutic relationships with adolescents and severely regressed adult patients, and it is usually acceptable.

Monetary gifts are trickier to handle, Mr. Dunn said. If a physician wants to help a patient who's in financial trouble, for instance, she could offer him free therapy instead of doling out cash. "Just be sure that you do the same for other patients," he warned.

Although it is natural for internists to forge friendships with some of their patients, it is unethical for a doctor to ask for special treatment outside of the medical setting. For instance, Mr. Dunn said that a doctor who has a hot stock tip should not approach his banker-patient about securing a loan for which he would not otherwise qualify.

Sexual misconduct

Sexual misconduct can range from inappropriate comments to sexual relations. Consent from an adult patient is never a defense for sexual misconduct by a physician, Mr. Dunn stressed, adding that six states consider sexual relations between physicians and their patients a criminal act.

Most doctors know a colleague who has fallen in love with and perhaps even married a former patient. But Mr. Dunn said that physicians should refrain from dating patients until the professional doctor-patient relationship has been terminated, preferably with a three- to six-month buffer.

What about gestures that might mistakenly be viewed as a sexual advance? When patients are distressed, Mr. Dunn said, it is generally acceptable to give a comforting pat of reassurance on the hand or shoulder. Physical contact that goes any farther, however, may be perceived as flirtatious or sexual and should be avoided.

Mr. Dunn also pointed out that malpractice insurance typically does not cover sexual misconduct lawsuits. Hospitals can generally be held liable if a physician engages in sexual misconduct while working there, even if he is not considered an employee of the hospital. In some cases, spouses and parents of a patient may also be able to sue a physician who has crossed an ethical boundary.

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