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Table of Contents

Think

Assess

 Patient: Autonomy

 Practitioner: Beneficence & Nonmaleficence

 Public Policy: Justice

Conclude

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2x Speed

47. Sexual Boundaries


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[The] medical practitioner, who, having just forbidden his cardiac patient indulgence in tobacco, alcohol and amorous intimacies, was asked by the victim, ’Tell me, doctor, if I give these things up, will I live longer?’ to which his medical practitioner replied with charm and candor,  ’No, but it’ll seem longer.’
~ Bernard Meyer


Abstract

The medical practitioner-patient relationship is unique and requires strict boundaries in order to protect the patient’s autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair). Both the American College of Physicians (ACP) and the American Medical Association (AMA) Code of Medical Ethics view sexual relationships between a practitioner and a current patient as unethical and detrimental to the patient’s well-being. The AMA also states that a practitioner should avoid nonsexual contact with a patient that may lead to romantic or sexual contact. The practitioner should also avoid sexual or romantic relations with anyone who directly affects the patient’s health. The patient-practitioner relationship is one-sided, with the patient divulging personal information, making the patient vulnerable to exploitation by the practitioner. It is therefore essential for the practitioner to maintain clear and distinct boundaries in order to protect the patient’s best interests.

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Think 

[47:1] It is always unethical for a medical practitioner to have sexual relations with a current patient. For former patients, it is also always unethical for a psychiatrist to have any sexual relations but unclear if any sexual contact for former patients is ethically accepted for non-psychiatric practitioners.

[47:2] The American College of Physicians (ACP) states:

Issues of dependency, trust, transference, and inequalities of power lead to increased vulnerability on the part of the patient and require that a physician [practitioner] not engage in a sexual relationship with a patient. It is unethical for a physician [practitioner] to become sexually involved with a current patient even if the patient initiates or consents to the contact.

[47:3] The American Medical Association (AMA) Code of Medical Ethics Opinion 9.1.1 states:

Romantic or sexual interactions between physicians [practitioners] and patients that occur concurrently with the patient-practitioner relationship are unethical. Such interactions detract from the goals of the patient-physician [practitioner] relationship and may exploit the vulnerability of the patient, compromise the physician’s [practitioner’s] ability to make objective judgments about the patient’s health care, and ultimately be detrimental to the patient’s well-being.

[47:4] Central to the art of medicine is the patient-practitioner relationship related to the patient, practitioner, and public policy. This relationship can result in long-lasting, if not permanent imprinting, making patients much more vulnerable to sexual exploitation, which is why it is unprofessional and unethical for a practitioner to have sexual relations with patients. 

[47:5] It is also unprofessional and unethical for a practitioner to have sexual relations with key third parties involved in the patient-practitioner relationship, such as parents, guardians, spouses, partners, or surrogates, when the interaction would exploit trust, knowledge, influence, or emotions derived from the patient-practitioner relationship resulting in compromised patient’s care.

Assess
Patient: 1) Autonomy

[47:6] Autonomy with its resultant informed consent can be deeply compromised due to the patient’s emotional and physical vulnerabilities with the practitioner and due to the practitioner’s emotionally compromised medical judgments. Therefore, maintaining strict sexual and emotional boundaries is essential for the existence of a legitimate patient-practitioner relationship and for attaining legitimate informed consent.

[47:7] The practice of medicine is supposed to be evidence-based, not emotionally based, because emotions and unconscious dependencies bring in so much decisional baggage that both the practitioner’s judgments are compromised and the patient’s informed consent is compromised, showing the necessity of establishing clear and distinct patient-practitioner boundaries.

Practitioner: 2) Beneficence & 3) Nonmaleficence

[47:8] The primary professional obligation is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the principles of beneficence (do good) and nonmaleficence (do no harm).

[47:9] The American Medical Association (AMA) Code of Medical Ethics 9.1.1 states:

Romantic or sexual interactions between physicians [practitioners] and patients … are unethical … detracts from the goals of the patient-physician [practitioner] relationship and may exploit the vulnerability of the patient, compromises the physician’s [practitioner’s] ability to make objective judgments …and is detrimental to the patient’s well-being.

[47:10] Sexual relations with a former patient or third party representative is also unprofessional, unethical, and sometimes illegal if the preceding patient-practitioner relationship with its trust, protected health information (PHI), influence, and emotional attachments are exploited in such a way that the previous patient, or involved third party, is vulnerable in the making of advances towards the practitioner, or in responding to the practitioner’s advances.

[47:11] The American Medical Association (AMA) 9.1.1 continues to state:

A physician [practitioner] who has reason to believe that nonsexual, nonclinical contact with a patient may be perceived as or may lead to romantic or sexual contact should avoid such contact.

[47:12] These professional boundaries can also involve key third parties involved in the patient’s care. The American Medical Association (AMA) 9.1.2 states:

Physicians [Practitioners] should avoid sexual or romantic relations with any individual whose decisions directly affect the health and welfare of the patient.

Public Policy: 4) Justice

[47:13] Justice (be fair) prohibits the exploitation of vulnerable citizens. The patient-practitioner relationship is a unique type of relationship with patients in a very vulnerable condition of needing to trust in their practitioner to provide that which will maximize their best interests. The patient-practitioner relationship is not reciprocal, as only the patient divulges personal information about the patient’s deepest desires and secrets. This places the patient in need of legal protection from practitioners who might consciously or unconsciously exploit their patients with unequal knowledge, unequal vulnerability, unequal dependency, and psychological transference.

Conclude

[47:14] It is imperative for the medical practitioner to be able keep the patient-practitioner relationship boundaries separate from any sexual, romantic, and familial association. These boundaries can be particularly difficult for practitioners who spend a large portion of their life interacting mainly with patients. Professional, legal, and ethical boundaries that prohibit sexual and romantic relations with patients are essential for maximizing the patient’s best interests.

[47:15] In summary, In conclusion, maintaining professional and ethical boundaries in the patient-practitioner relationship is vital for preserving patient autonomy, practitioner beneficence, nonmaleficence, and social justice. Medical practitioners must avoid sexual and romantic relationships with patients or key third parties involved in the patient’s care, as such relationships can compromise informed consent, exploit vulnerabilities, and ultimately be detrimental to the patient’s well-being. By adhering to these boundaries, practitioners can uphold the highest standards of ethical and professional conduct in their practice.

(See also: 9. Conflict of Interest, 18. Financial Disclosures, 21. Gifts, and 46. Self-Treatment & Family-Treatment)

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47. Review Questions

1. Sometimes it is ethical for a practitioner to have sexual relations with a current patient.

2. The patient-practitioner relationship can result in long-lasting, if not permanent, imprinting, making patients much more vulnerable to sexual exploitation, which is why it is unprofessional and unethical for a practitioner to have sexual relations with patients.

3. It is unprofessional and unethical for a practitioner to have sexual relations with key third parties involved in the patient-practitioner relationship, such as parents, guardians, spouses, partners, or surrogates, when the interaction would exploit trust, knowledge, influence, or emotions derived from the patient-practitioner relationship resulting in compromised patient’s care.

4. Autonomy with its resultant informed consent can be deeply compromised due to the patient’s emotional and physical vulnerabilities with the practitioner and due to the practitioner’s emotionally compromised medical judgments.

5. The practice of medicine is supposed to be evidence-based, not emotionally based, because emotions and unconscious dependencies bring in so much decisional baggage that both the practitioner’s judgments are compromised, and the patient’s informed consent is compromised, showing the necessity of establishing clear and distinct patient-practitioner boundaries.

6. The patient-practitioner relationship is not reciprocal as only the patient divulges personal information about the patient’s deepest desires and secrets. This places the patient in need of legal protection from practitioners who might consciously or unconsciously exploit their patients with unequal knowledge, unequal vulnerability, unequal dependency, and psychological transference.

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47. Clinical Vignettes

1. Ms. Jennifer Lee is a 38-year-old software engineer who has been seeing Dr. Maria Hernandez, a 45-year-old psychiatrist, for the treatment of depression and anxiety for the past six months. During one of their sessions, Ms. Lee expresses her attraction to Dr. Hernandez and asks her out on a date. Dr. Hernandez is aware that it is always unethical and illegal for a psychiatrist to engage in a romantic or sexual relationship with any patient, whether current or past, regardless of the circumstances [47:2]. She is also aware that abruptly terminating the therapeutic relationship could be considered patient abandonment, which is both ethically and legally problematic. What should Dr. Hernandez do?

2. Mr. James Parker is a 28-year-old construction worker who has been seeing Dr. Rachel Chen, a 35-year-old family practitioner, for the treatment of chronic back pain. During one of their appointments, Mr. Parker makes a suggestive comment to Dr. Chen and touches her inappropriately. Dr. Chen is aware that it is always unethical and illegal for a practitioner to engage in a romantic or sexual relationship with a patient, and she is concerned about the safety and well-being of both Mr. Parker and herself. What should Dr. Chen do?

3. Ms. Maria Rodriguez is a 35-year-old restaurant owner who has been seeing Dr. Alex Torres, a 42-year-old primary care practitioner, for her annual physical exams for the past five years. During one of their appointments, Dr. Torres makes a comment about Ms. Rodriguez's appearance that makes her feel uncomfortable. Ms. Rodriguez is concerned that Dr. Torres has overstepped professional boundaries and may be behaving inappropriately. What should Dr. Torres do?

4. Ms. Sarah Park is a 24-year-old graduate student who is seeking treatment for anxiety and depression from Dr. Michael Kim, a 35-year-old clinical psychologist. During one of their therapy sessions, Ms. Park tells Dr. Kim that she has feelings for him and asks him to engage in a romantic and sexual relationship with her. Dr. Kim is surprised and unsure of how to respond. What should Dr. Kim do?

5. Dr. Maria Rodriguez is a 45-year-old gynecologist who has been seeing Mrs. Karen Smith, a 32-year-old patient, for annual check-ups for the past two years. During a routine exam, Dr. Rodriguez begins to make suggestive comments and behaves inappropriately towards Mrs. Smith, who is concerned that Dr. Rodriguez may be overstepping professional boundaries. What should Mrs. Smith do?

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47. Reflection Vignettes

1. Mr. Isaac Franklin a 27-year-old third-year medical student is being mentored into the practice of medicine at a local hospital. Ms. Chloe Eaton, a 24-year-old recent graduate willingly provides an informed consent for Mr. Franklin to observe and practice getting a patient’s history and physical (H&P). Other activities included making sure that the Ms. Eaton was substantially informed of the risks and benefits of the treatment options and that all of the her questions were answered under the supervision of the primary care practitioner. The Mr. Franklin was diligent and responsible, spending extra time with the Ms. Eaton. However, when the Ms. Eaton and Mr. Franklin were together, they both fell deeply in love with each other.

This situation needs to be addressed promptly. The Mr. Franklin must inform their supervisor or the attending physician about the situation. It is crucial to ensure that the Ms. Eaton’s medical care is not affected in any way, and that their privacy and confidentiality are protected. The medical school should have policies and guidelines in place to handle such situations, and the Mr. Franklin should follow them accordingly. Additionally, Mr. Franklin may consider seeking counseling or guidance from the medical school's mental health services to address the personal and emotional impact of the situation.

Think

Assess

  Patient: Autonomy

  Practitioner: Beneficence & Nonmaleficence

  Public Policy: Justice

Conclude

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2. Dr. Emily Johnson is a 34-year-old family practitioner at a busy medical center. One day, a patient named John, a 28-year-old construction worker, comes to her clinic complaining of severe back pain that has been troubling him for several weeks. Dr. Johnson diagnoses John with a herniated disc and prescribes him pain medication and physical therapy. Over the next few weeks, John visits the clinic for follow-up appointments and Dr. Johnson works closely with him to monitor his progress and adjust his treatment plan as necessary. A couple of months later, Dr. Johnson attends a friend's party, where she runs into John. They both enjoy each other's company and end up spending most of the night talking and laughing together. As they leave the party, John asks if he can take Dr. Johnson out on a date. Dr. Johnson is taken aback by the request and realizes that she has developed feelings for John as well. She knows that getting romantically involved with a current or former patient is not ethical, but she finds herself struggling to resist the strong attraction she feels towards him. As the days pass, Dr. Johnson finds herself thinking about John more and more often. She wonders if she should pursue a relationship with him or if she should distance herself to maintain professional boundaries. Dr. Johnson faces a difficult decision as she tries to balance her personal feelings with her professional obligations as a practitioner. It might be wise to consult with one of her colleagues and her professional association for guidance on how to handle the situation appropriately. By prioritizing John's best interests and upholding ethical and legal obligations, Dr. Smith was able to navigate the potential conflict of interest and maintain the integrity of the patient-practitioner relationship.

Think

Assess

  Patient: Autonomy

  Practitioner: Beneficence & Nonmaleficence

  Public Policy: Justice

Conclude

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