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• Private or intimate relations between doctor and patient: is zero tolerance warranted?
  Wolfgang L. Spiegel
  Published on: 21 November 2003

• Published on: 21 November 2003

  Private or intimate relations between doctor and patient: is zero tolerance warranted?

  • Wolfgang L. Spiegel, General Practitioner
  • Other Contributors:
    • Tanja Colella, Philip W. Lupton

  Dear Editor

  Five arguments put forward for a "zero tolerance policy" have been summarised by Cullen, who, we believe, has also hinted at their weaknesses.[1]

  There is the "empirical" claim that sexual contact in the P-P-R is "almost always harmful to the patient". But the evidence in support of this argument consists mainly of case reports and small case series of patients receiving psychotherapy. No represen...

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  Dear Editor

  Five arguments put forward for a "zero tolerance policy" have been summarised by Cullen, who, we believe, has also hinted at their weaknesses.[1]

  There is the "empirical" claim that sexual contact in the P-P-R is "almost always harmful to the patient". But the evidence in support of this argument consists mainly of case reports and small case series of patients receiving psychotherapy. No representative studies are known. There is no evidence to suggest that harm following a failed relationship with a health professional is any different to that following the break up of a relationship with a non health professional.

  Personally, we do not doubt that intimate relationships between doctor and patient have the potential to be harmful to patients´ and can have negative effects on patients´ future ability to establish a trusting relationship with a doctor.

  The second argument considered by Cullen is based on "principles": To look at the relevant underlying ethical principles and examine whether the proposed course of action is consistent with each them. Zelas has proposed a set of preconditions to be met if sexual contact is to be acceptable: Trust, power balance and consent have been identified. Cullen states that even if one accepts trust, power balance, and consent as necessary conditions they do not justify a zero tolerance position. We disagree with this conditions. Where trust is, balance of power is dispensable.

  The third, "virtues-based", argument suggests that the virtues ethicist considers the virtues necessary in a good doctor and attempts to demonstrate that a virtuous doctor can not enter into a sexual relationship with a patient. Cullen criticises that this argumentation twists the concept of virtues until virtues become duties be followed regardless of circumstances. We would add that when advice how to act is based merely on virtues, the principle of action may not be connected with individual reality and may lack contact with the cultural environment.

  The fourth argument in favour of a zero tolerance is an "a priori" one. It is argued that the P-P-R is defined as displaying certain properties, e.g. the P-P-R must have "property X" (emotional distance and detachment). Sexual contact cannot have “property X”. Is it not unrealistic and does it not disregard professional principles, in particular those applied in specialties requiring a P-P-R of a close and personal nature, to demand affective neutrality and detachment between doctor and patient?

  Cullen calls the fifth argument "counterfactual". If sexual contact between doctors and patients were allowed then there would be unacceptable consequences. A typical unacceptable consequence would the breakdown of the trust essential to a P-P-R. The argument asserts that the consequences of a policy that allowed sexual contact between doctors and patients would be harmful. Isn't a policy of prohibition more likely to undermine the patient's trust in his/her doctor? Can right thinking and right feeling ever be enforced? If right doing has to be enforced, would it not give rise to fears that laws might be broken?

  The history of prohibition is a long one, and rarely has to report about successes, where attitudes or behaviours were supposed to be enforceable. According to Leggett the injunction against sexual intimacies still functions to preserve the good name of the healing professions. Others have written urging that while such responses may be appropriate, they should be the outgrowth of serious considerations and open-minded contemplation of the ethical, moral, and therapeutic issues involved. We would like to stimulate debate on how doctors and therapists should handle sexual feelings towards patients and whether there is adequate cause for the injunction prohibiting any sexual relationships with patients and for its enforcement by ethical and disciplinary bodies. We look forward to a social climate where the doctor, when experiencing a feeling of personal affinity with a patient, is encouraged to reflect on it so as to identify restricting factors and possible consequences. Patients may not understand the ethics or the potential harm involved in a doctor-patient social or sexual relationship, but the doctor should. We have summarised elsewhere important factors to be taken into account when considering initiation of a romantic relationship with a patient.

  Reference

  (1) Cullen RM. Arguments for zero tolerance of sexual contact between doctors and patients. J Med Ethics 1999; 25: 482-486.

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  Conflict of Interest:
  None declared.

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