Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients

doi:10.1016/S0002-9378(96)70169-2

American Journal of Obstetrics and Gynecology

Volume 175, Issue 2, August 1996, Pages 496-500

https://doi.org/10.1016/S0002-9378(96)70169-2 Get rights and content

Abstract

OBJECTIVE: This article proposes ethically justified guidelines that should govern the ethical obligations of obstetrician-gynecologists when they experience sexual feelings toward patients. STUDY DESIGN: We reviewed literature on physician-patient sexual contact and related that literature to ethical principles. RESULTS: Existing guidelines that prohibit sexual contact between physicians and patients are based on an ethical argument that such relationships violate the ethical principles of respect for both autonomy and beneficence. This argument is incomplete because patients can provide valid consent for sexual relationships with their own obstetrician-gynecologists. CONCLUSION: We propose a virtues-based ethical argument that is independent of informed consent for governing sexual relationships between obstetrician-gynecologists and their patients. In the context of the physician-patient relationship the professional virtues of self-effacement and self-sacrifice obligate the obstetrician-gynecologist to set aside and never act on feelings of sexual attractiveness toward patients. (Am J Obstet Gynecol 1996;175:496-500.)

Section snippets

PREVALENCE, ATTITUDES AND EVIDENCE FOR HARM

There are four published studies estimating the prevalence of sexual contact between obstetrician-gynecologists and patients.5, 6, 7, 8 In a 1973 Californian survey that sampled from several medical specialties including gynecology, the career prevalence of “erotic” behavior including sexual intercourse with patients was 7%.⁵ A Canadian survey of obstetrician-gynecologists found that 3% of the male respondents and 1% of the female respondents reported sexual involvement with a patient.⁶ In the

CURRENT ARGUMENTS AGAINST SEXUAL RELATIONSHIPS

There exists a line of argument against sexual relationships between physicians and their patients that has gained considerable prominence in the literature.1, 3, 4, 14, 15 This line of argument begins with the claim that conditions for valid consent to such relationships usually do not exist on the patient's part. As a result of vulnerability, transference phenomena, fear in the presence of authority, and other factors, the crucial condition of voluntariness for an informed consent to a sexual

A VIRTUES-BASED ARGUMENT

Is there an ethical argument concerning sexual relationships with patients that can be developed independently of consent? Such an argument would have to be independent of ethical principles in general and of the ethical principle of respect for autonomy in particular, because this principle is the basis for consent. A virtues-based argument, we will now show, meets this test.

Virtues are traits or habits of character that routinely blunt self-interest, so that we can see and routinely act to

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Citation Excerpt :
Self-sacrifice requires psychiatrists to put aside their sexual interest in patients when it occurs. Those two virtues, linked with integrity, form a bulwark against acting on a sexual attraction toward a patient.31 Publicized occasions in which physicians engage in sexual contact with patients can be very damaging to the profession, undermining trust in all medical professionals.
The moral foundation of medical lead ership: The professional virtues of the physician as fiduciary of the patient
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Leadership in medicine, as in other settings, should be based on values that provide appropriate direction for the use of institutional power and authority. Leadership also requires managerial competence. Managerial knowledge and skills can be used for worthy and unworthy goals and therefore require a moral foundation. Using the methods of ethics, we argue that the concept of the physician as the moral fiduciary of the patient should be the moral foundation of management decisions by physician-leaders. We take this concept from the history of eighteenth century medical ethics and develop it in terms of four professional virtues—self-effacement, self-sacrifice, compassion, and integrity. We apply these four virtues to show how physician-leaders should create a moral culture of professionalism in health care organizations. We then identify four vices—unwarranted bias, primacy of self-interest, hard-heartedness, and corruption—that undermine this moral culture of professionalism. Because health care organizations now play a central role in patient care, their moral culture and therefore physician-leaders have become vital elements in physicians being able to maintain their professionalism. Physician-leaders bear major responsibility to shape organizational cultures that support the fiduciary professionalism of physicians. (Am J Obstet Gynecol 2001;184:875-80.)
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Violence against women is one reflection of the unequal power relationship between men and women in societies. Reflections of this inequality include marriage at a very young age, lack of information or choice about fertility control and forced pregnancy within marriage. The different forms of violence against women are: domestic violence and rape, genital mutilation or, gender-based violence by police and security forces, gender-based violence against women during armed conflict, gender-based violence against women refugees and asylum-seekers, violence associated with prostitution and pornography, violence in the workplace, including sexual harassment. Violence against women is condemned, whether it occurs in a societal setting or a domestic setting. It is not a private or family matter. The FIGO Committee for the Study of Ethical Aspects of Human Reproduction released statements to physicians treating women on this issue. Physicians are ethically obliged to inform themselves about the manifestations of violence and recognize cases, to treat the physical and psychological results of violence, to affirm to their patients that violent acts toward them are not acceptable and to advocate for social infrastructures to provide women the choice of seeking secure refuge and ongoing counselling.
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^☆: From the Center for Medical Ethics and Health Policy, Baylor College of Medicine,^a the Department of Obstetrics and Gynecology, The New York Hospital - Cornell Medical Center,^b and the Department of Psychiatry and Behavioral Science, University of Auckland.^c

^☆☆: Reprint requests: Laurence B. McCullough, PhD, Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.

^★: 0002-9378/96 $5.00 + 0 6/1/73369

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Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients☆,☆☆,★

Abstract

Section snippets

PREVALENCE, ATTITUDES AND EVIDENCE FOR HARM

CURRENT ARGUMENTS AGAINST SEXUAL RELATIONSHIPS

A VIRTUES-BASED ARGUMENT

Sexual misconduct in the practice of medicine

JAMA

Code of medical ethics. Current opinions of the Council on Ethical and Judicial Affairs of the American Medical Association

Sexual misconduct in the practice of obstetrics and gynecology: ethical considerations

Final report of the task force on sexual abuse of patients

A survey of physicians' attitudes and practices regarding erotic and non erotic contact with patients

Am J Psychiatry

Patient-physician sexual involvement: a Canadian survey of obstetrician-gynecologists

Can Med Assoc J

Sexual contact in the doctor-patient relationship in the Netherlands

BMJ

Physician-patient sexual contact: prevalence and problems

West J Med

Psychiatrist-patient sexual contact: results of a national survey. I. Prevalence

Am J Psychiatry

A national survey on physicians' attitudes toward social and sexual contact with patients

South Med J