David Shaw rejects my suggestion that, although it is not necessarily unethical, it might well be unprofessional for a doctor to perform euthanasia on or to have sex with his or her patients.[1,2] However, his argument is unconvincing.

According to him: '...if something is really contrary to a professional's role, it is almost certain to be unethical in some respect. McLachlan provides the example of doctors having sex with their patients as an example of unprofessional but not unethical behaviour. It is somewhat surprising that he simply states this as fact: many would argue that this behaviour is both unprofessional and unethical. It is unethical because it could be an abuse of power, there could be coercion involved, it might affect how the patient is treated with harmful consequences, and there might even be a therapeutic misconception (no pun intended).'[1] It would be unethical on the part of the patient or the doctor if a particular act of sex between a patient and a doctor were an abuse of power by the patient or the doctor. It does not follow that all acts of sex between patients and doctors are unethical. It is beside the point to say that if a doctor has sex with his or her patient this could be an abuse of power and coercion could be involved since any sexual relationship between adult human beings could be an abuse of power and could involve coercion. Considerations of this sort - even if they are not conclusive and not, even, particularly plausible - are relevant to the argument that it should be always considered unprofessional for a doctor to have sex with his or her patients even if they. However, they have no bearing on the implausible assertion that it is necessarily unethical for doctors to have sex with their patients. Not all sexual relationships between doctors and their patients involve an abuse of power. Not all sexual relationships between doctors and their patients are coercive. It is not only needlessly patronising to patients and misplaced paternalism to say that, because it is an abuse of the doctor's power and/or it is coercive, patients cannot give valid consent to sexual relations with their own doctors, it is false. If we were not able to give valid, authorising consent to have sexual intercourse with our doctors, we would scarcely be able to give our consent to what might be considered more intimate or hazardous procedures such as, say, rectal examinations and heart transplants. If we cannot be considered to be competent adults in the one instance, we should not be so considered in the others. Any relationship between a doctor and a patient could be an abuse of power and could be coercive whether or not it is a sexual one. Furthermore, it is a mistake to assume that it is the doctor rather than the patient who will be coercive or an abuser of power in a sexual relationship between a doctor and a patient that happens to be unethical. There are various sorts of powers that people can have. We cannot always say in any particular relationship who has more power. Not all sorts of power are commensurate. For instance, President Kennedy had different sorts of powers than Lee Harvey Oswald had. He who might have been thought the less powerful of the two men killed the other one wrongfully and abusively. In situations of unequal power where this is abuse and exploitation, it is not always the weaker party who exploits or abuses the other. It is the powers that we are able and prepared to exercise rather than the powers that could have been exercised in particular relationships that matter. In some respects and in some contexts, doctors have more to fear from their patients than patients have to fear from their doctors. For instance, the fear that a patient might make an accusation against his doctor -whether or not it is true - might well be more compelling for the doctor and more firmly grounded than any fear the patient would have about an accusation from his doctor against him or her. This might be a good reason for thinking that it is unprofessional even if not unethical for doctors to have sex with their patients. In various contexts, it is what might be thought of as weaker people who are more dangerous and threatening. If, say, you wander about New York or London late at night, it is not, for instance, Bill Gates, David Cameron, Prince Philip or David Beckham but some poor, puny teenager who is more likely to try to mug you. Shaw continues: 'McLachlan also states that "the BMA would be a laughing stock if it were thought to permit doctors to kill their own patients but not to have sex with them". This is a hasty comment: in fact, killing one's patient at their request could be both in the patient's best medical interests and a professional duty; having sex with one's patient would be neither, in addition to being unethical for the aforementioned reasons.'[1] Killing one's patient could be seen as being in the best medical interests of patients and could be seen to be a professional duty of a doctor. I don't see it that way but other people could and do. I don't deny this. However, to have sex with a patient might also be considered to be in the medical interests of a patient. My point is that, even if it is in medical interest of a patient and even if it is not considered to be unethical, there might still be objections to it on the grounds of professional propriety. Shaw is clearly unaware that, in the past, some doctors did think that it was appropriate in the case of what were considered the hysterical illness of some spinster patients to bring them to orgasm by digital manipulation. Indeed, doctors invented the vibrator, not as a sex toy, but as a medical instrument to facilitate such medical treatment. It is possible to imagine that some patients might want to have sex and want to have sex with their doctors. They might think that this was a medical need. They might be right. In my view, it is no more appropriate that one should be given active euthanasia on the NHS than that one should be given sex or otherwise brought to an orgasm. Whether or not it is considered as medical treatment is irrelevant, in my view. Not all that a person who is also a patient needs should be considered as medical treatment. Not all that could be considered as medical treatment should be provided by doctors, especially not by doctors who work for the NHS and are paid from the public purse. Rape is wrong no matter what other people think about the action. However, unprofessional conduct can cease to be such when the attitude of others towards it changes. For instance, sexual relations, particularly homosexual relations between combat troops, particularly when those involved are of different ranks is hardly inherently unethical yet, in many armies, this would be considered as unprofessional conduct. One would imagine that, in the future, attitudes towards such actions might change significantly.

Similarly, the nature of appropriate professional conduct might be different in different context and in different social systems. What is appropriate conduct for a doctor in a system of private healthcare might differ in some respects from what is appropriate for a doctor within a publicly provided and financed healthcare system.

Shaw's contention that '...if something is really contrary to a professional's role, it is almost certain to be unethical in some respect' should be treated with caution.[1]

1. Shaw D. A defence of a new perspective on euthanasia. J Med Ethics 2011;37:123-5, 124. 2 McLachlan HV. Assisted suicide and the killing of people? Maybe. Physician-assisted suicide and the killing of patients? No: the rejection of Shaw's new perspective on euthanasia. J Med Ethics 2010;36:306-9.

Conflict of Interest:

None declared