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PEDIATRICS Vol. 104 No. 2 August 1999, pp. 334-336
AMERICAN ACADEMY OF PEDIATRICS:
Appropriate Boundaries in the Pediatrician-Family-Patient
Relationship
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ABSTRACT |
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Recommendation
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All professionals are concerned about maintaining the appropriate limits in their relationships with those they serve. Romantic and sexual involvement between physicians and patients is unacceptable. Pediatricians also must strive to maintain appropriate professional boundaries in their relationships with the family members of their patients. Pediatricians should avoid behavior that patients and parents might misunderstand as having sexual or inappropriate social meaning. The acceptance of gifts or nonmonetary compensation for medical services has the potential to affect adversely the professional relationship.
Physicians and the public recognize the need for high moral
standards and accountability in medicine. Most commonly, the focus of
concern involves physician competence and integrity as demonstrated by
such measures as board certification, hospital credentialing, peer
review of practice, physician assistance programs, and malpractice litigation. Physician behavior is guided by various practice
guidelines, review articles, policy statements by professional
organizations, etc, as well as applicable law and regulations. Codes of
ethics for physicians have a role in addressing personal and other
nontechnical aspects of physician conduct, as exemplified by the
American Medical Association's periodically updated code1
and the 1997 document from the American College of Obstetricians and
Gynecologists.2 The American Academy of Pediatrics (AAP)
also has issued a policy entitled "The Use of Chaperones During the
Physical Examination of the Pediatric Patient."3
This statement considers the appropriate professional boundaries
between physicians who care for children, their patients, and the
patients' family members. The AAP believes that physicians must
exercise substantial care in nonprofessional relationships with
patients and families to promote the highest possible degree of trust
in the doctor-patient-family relationship.
It is difficult to find reliable data on the prevalence of sexual
contact between physicians and their patients or their patients' family members. Position papers about psychiatrists4 and
obstetricians5 comment on the lack of well-conducted reliable studies on professional boundary violations by physicians. Attention to the subject, in the form of complaints against
practitioners and publications in professional journals, has been more
prominent among psychiatrists and
obstetrician-gynecologists.6-10 Interpersonal
entanglements raise at least two serious questions. First, can a
patient or family member make clear and free choices to accept or
reject affections, especially sexual, in the context of the unavoidably
unequal physician-patient-family relationship? Second, once such
intimacy develops, can the parties maintain a proper and effective
therapeutic relationship?
Because pediatricians provide counseling services for patients and
families, the concerns closely parallel those faced by mental health
professionals. Pediatricians who feel sexually attracted to children
may put patients at risk of sexual abuse or
exploitation.11 More likely, however, pediatricians may be
misunderstood when they first discuss sexual maturation and sexuality
with patients.12 Similarly, examination of an
adolescent's maturing genitals or breasts during an office visit may
be distressing or misunderstood by the patient, especially if a parent
or chaperone is not in the examining room.3 Pediatricians
should develop and follow clear and consistent office policies about
the presence of a chaperone during parts of the physical examination,
taking into account local customs, families' religions and cultural
traditions, and the need for patient privacy.
Pediatricians also interact with the parents or guardians of their
patients, although seldom in doctor-patient relationships. Pediatricians are responsible for maintaining appropriate professional boundaries with the families of their patients, although their obligations toward them may be somewhat different from those for their
patients.
There is an inherent risk of exploitation for patients or family
members who depend on the knowledge and authority of the physician,
especially in cases involving nonroutine health care. The success of
the doctor-patient or doctor-parent relationship depends on the ability
of the patient or family member to trust the physician completely.
Patients and family members legitimately expect to feel physically and
emotionally safe in professional relationships with physicians. They
should not feel vulnerable to romantic or sexual advances while
receiving medical care for themselves or their children. In addition,
children should be free from concern that their treatment may be
compromised by a nonprofessional relationship between a parent and
their physician. Children should not have to worry about
confidentiality or have anxiety over the potential for the physician to
have a conflict of loyalty because of the physician's involvement with
the parent.
Patients or family members to some extent identify with and feel
gratitude toward physicians. At times, these feelings may result in
efforts to initiate a nonprofessional relationship with the physician
or may leave the patient or family member consciously or otherwise
unwilling or unable to reject a physician's romantic or sexual
advances. Any confusion between complex professional bonds and
extraprofessional personal relationships may leave the patient or
family member unable to exercise the best judgment or choice about
medical matters.
The clinical judgment of physicians who become intimately involved with
a patient or family member may become clouded and they may breach their
professional responsibilities. Whether this possibility extends to
close family members of patients is somewhat less clear. If the
intimacy develops in the context of a patient's serious illness,
concerns about exploitation of the family member's dependency on the
physician arise. Under these circumstances, the physician is
well-advised to end the professional relationship after ensuring the
transfer of the patient's medical care to another appropriate
practitioner. Nevertheless, proscriptions on physicians pursuing
relationships with parents or adult siblings of their patients in
unusual circumstances may result in unnecessary and inappropriate
restrictions on the physician's personal life.
Physicians usually prefer warm, friendly relationships with their
patients. The need to avoid untoward personal intimacy should not lead
to a cold, indifferent manner in their interactions with patients or
family members. Many cultures expect physical expressions of care and
concern in times of personal crisis, including sickness. Physicians
might well be seen as unsympathetic and excessively remote if they
avoid handshakes or other socially approved touching during emotional
encounters with families. In most social groups in the United States,
interaction with children is likely to involve appropriate physical
contact, such as hugging.
Physicians should be aware of their patients' customs and personal and
religious beliefs. In addition, it may be helpful to recognize that
some kinds of touching may be confusing or offensive to children,
depending on their stage of physical and emotional maturation. For
example, certain children may have strong preferences about whether
their physical examination is performed by a male or female physician,
or whether someone else besides the physician is present during the
examination. Anticipatory discussion of these issues should reduce
fears and misunderstandings and lead to enhanced physician, patient,
and family comfort.
Physicians also have an obligation to recognize that physical
interaction is not the only means by which humans communicate sexually.
Body language and verbal expressions also convey attitudes and emotions
that may provoke strong feelings. Because socioeconomic or cultural
groups may differ in what they consider acceptable or expected
behavior, it is usually best to ask patients and parents their
preferences about how they would like to be addressed.10 For example, pediatricians should use neutral language or names in
addressing patients, rather than employing terms of endearment like
"honey" or "dear." Words that could be seen as evaluative or
provocative when referring to body parts, such as the breasts, should
be avoided.
Physicians may receive gifts from patients or parents, especially
after providing help for an especially troubling health-related problem. Under most circumstances, gifts have a far more symbolic than
material value.13 For most pediatricians, accepting modest
gifts does not involve a serious conflict Patients or family members may want to compensate physicians with
an exchange of services or with barter. For example, an adolescent or
the adolescent's parents may offer the patient's services as a
baby-sitter or gardener in lieu of monetary payment for care. Such
arrangements vary legitimately with local custom and the economic
circumstances of patients and families. However, problems may arise
about exactly what services constitute adequate compensation for
professional care and the appropriateness of increased personal contact
between the patient or family member and the physician. Nonmonetary
payments, as with gifts, may become precursors to boundary
violations and should be approached with caution.
ROMANTIC AND SEXUAL RELATIONSHIPS
INADVERTENT SEXUALITY IN THE PHYSICIAN-PATIENT
RELATIONSHIP
GIFTS OR OTHER EXPRESSIONS OF AFFECTION OR GRATITUDE
in fact, refusal of a gift
may constitute a social or cultural affront. As the monetary worth of
the gift increases, however, so does the psychological and ethical
difficulty in maintaining appropriate boundaries in the professional
relationship. When the physician feels uncomfortable with a gift that a
family insists on delivering, he or she should voice the concern, and
suggest acceptable alternatives such as a charitable donation in the
physician's name. Highly valued gifts may indicate that these
boundaries have been crossed. The patient or loved one may have
misinterpreted the physician's earlier behavior or may be inviting the
physician to engage in a relationship that could compromise medical
judgment and action.
OTHER CONSIDERATIONS
RECOMMENDATIONS
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Abstract
Recommendation
References
COMMITTEE ON BIOETHICS, 1998-1999
Robert M. Nelson, MD, PhD, Chairperson
Jeffrey R. Botkin, MD, MPH
Marcia Levetown, MD
Kathryn L. Moseley, MD
John T. Truman, MD
Benjamin S. Wilfond, MD
LIAISON REPRESENTATIVES
Alessandra (Sandi) Kazura, MD
American Academy of Child and Adolescent Psychiatry
Watson A. Bowes, Jr, MD
American College of Obstetricians and Gynecologists
Ernest F. Krug III, MD
American Board of Pediatrics
SECTION LIAISON
Donna A. Caniano, MD
Section on Surgery
G. Kevin Donovan, MD, MLA
Section on Bioethics
CONSULTANT
Joel E. Frader, MD
LEGAL CONSULTANT
Dena S. Davis, JD, PhD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics.
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REFERENCES |
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Abstract
Recommendation
References
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- American Medical Association, Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions With Annotations. Chicago, IL: American Medical Association; 1997
- American College of Obstetricians and Gynecologists. Code of Professional Ethics. Washington, DC: American College of Obstetricians and Gynecologists; 1997
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American Academy of Pediatrics, Committee on Practice and Ambulatory Care
The use of chaperones during the physical examination of the pediatric patient.
Pediatrics.
1996;
98:1202
[Abstract/Free Full Text] - Hundert EM, Appelbaum PS Boundaries in psychotherapy: model guidelines. Psychiatry. 1995; 58:345-356 [Medline]
- McCullough LB, Chervenak FA, Coverdale JH Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients. Am J Obstet Gynecol. 1996; 175:496-500 [CrossRef][Medline]
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American Medical Association Council on Ethical and Judicial Affairs
Sexual misconduct in the practice of medicine.
JAMA.
1991;
266:2741-2745
[Abstract/Free Full Text] - Gartrell NK, Milliken N, Goodson WH, Thiemann S, Lo B Physician-patient sexual contact: prevalence and problems. West J Med. 1992; 157:139-143 [Medline]
- Lamont JA, Woodward C Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists. CMAJ. 1994; 150:1433-1439 [Abstract]
- American College of Obstetricians and Gynecologists Committee on Ethics. Sexual Misconduct in the Practice of Obstetrics and Gynecology: Ethical Considerations. Washington, DC: American College of Obstetricians and Gynecologists; Committee Opinion No. 144: November 1994
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Gabbard GO,
Nadelson C
Professional boundaries in the physician-patient relationship.
JAMA.
1995;
273:1445-1449
[Abstract/Free Full Text] - Newberger CM, Newberger EH. When the pediatrician is a pedophile: is there a moral defect in the practice of professional regulation? In: Maney A, Wells SJ, eds. Professional Responsibilities in Protecting Children: A Public Health Approach to Child Sexual Abuse. New York, NY: Praeger; 1988:65-72
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Silber TJ
False allegations of sexual touching by physicians in the practice of pediatrics.
Pediatrics.
1994;
94:742-745
[Abstract/Free Full Text] - Drew J, Stoeckle JD, Billings JA Tips, status and sacrifice: gift giving in the doctor-patient relationship. Soc Sci Med. 1983; 17:399-404
Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
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