Ethics Manual

Highlights

Patients Near     the End of Life Advance Care     Planning Problems of     Life-Sustaining     Treatments

Physician and Patient

The patient-physician relationship entails special obligations for the physician to serve the patient's interest because of the specialized knowledge that physicians hold and the imbalance of power between physicians and patients. The physician's primary commitment must always be to the patient's welfare and best interests, whether the physician is preventing or treating illness or helping patients to cope with illness, disability and death. The physician must support the dignity of all persons and respect their uniqueness.  

At the beginning of a patient-physician relationship, the physician must understand the patient's complaints, underlying feelings, goals and expectations. After patient and physician agree on the problem and the goal of therapy, the physician presents one or more courses of action. If both parties agree, the patient may authorize the physician to initiate a course of action. The physician can then accept that responsibility. The relationship has mutual obligations: The physician must be professionally competent, act responsibly and treat the patient with compassion and respect, and the patient should understand and consent to the treatment that is rendered and should participate responsibly in the care. 

Initiating and Discontinuing the Patient-Physician Relationship

By history, tradition and professional oath, physicians have a moral obligation to provide care for ill persons. A physician must not discriminate against a class or category of patients. An individual patient-physician relationship is formed on the basis of mutual agreement on medical care for the patient. In the absence of a pre-existing relationship, the physician is not ethically obliged to provide care to an individual person unless no other physician is available, as is the case in some isolated communities or when emergency treatment is required. Under these circumstances, the physician is morally bound to provide care and, if necessary, to arrange for proper follow-up. Physicians may also be bound by contract to provide care to beneficiaries of participating health plans. Physicians and patients may have different concepts of the meaning and resolution of medical problems. The care of the patient and satisfaction of both parties are best served if both physician and patient discuss their expectations and concerns. Although the physician must address the patient's concerns, he or she is not required to violate fundamental personal values, standards of scientific or ethical practice, or the law. When the patient's beliefs — religious, cultural, or otherwise — run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient. If the physician is unable to carry out the patient's wishes after seriously attempting to resolve differences, the physician should transfer the care of the patient. Under exceptional circumstances, the physician may discontinue the professional relationship by notifying the patient and with the approval of the patient, transfer to another physician the information in the record, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process. Continuity of care must be assured to the best of the physician's ability. Physician-initiated termination is a serious event, especially if the patient is acutely ill and should be undertaken only after genuine attempts are made to understand and resolve differences.

Sexual Contact between Physician and Patient

Issues of dependency, trust, transference and inequalities of power lead to increased vulnerability on the part of the patient and require that a physician not engage in a sexual relationship with a patient. It is unethical for a physician to become sexually involved with a current patient even if the patient initiates or consents to the contact. Even sexual involvement between physicians and former patients raises concern. The impact of the patient-physician relationship may be viewed very differently by physicians and former patients and either party may underestimate the influence of the past professional relationship. Many former patients continue to feel dependency and transference toward their physicians long after the professional relationship has ended. The intense trust often established between physician and patient may amplify the patient's vulnerability in a subsequent sexual relationship. A sexual relationship with a former patient is unethical if the physician "uses or exploits the trust, knowledge, emotions or influence derived from the previous professional relationship". Because it may be difficult for the physician to judge this influence, we advise consultation with a colleague or other professional before becoming sexually involved with a former patient