Doctor-Patient Boundaries: Road Rules and Red Flags by Lee H. Beecher, M.D.

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Boundaries are the "rules of the road" that define and secure professional, trusting, therapeutic relationships between doctors and patients. Respecting and understanding boundaries between professionals and patients are essential for optimal therapeutic outcomes. And defining and enforcing professional-patient boundaries are key to assuring the public that doctors seek to do no harm to patients.

Establishing and maintaining professional roles and interpersonal boundaries are the sole responsibility of the physician and other treating clinicians. The time-honored doctor-patient relationship first described in Hippocratic texts 2,500 years ago framed expectations that the patient must be able to be truthful with the doctor; and that the doctor will safeguard the patient's confidences, know and respect the patient’s beliefs and expectations about his illness, and be caring and nonjudgmental in treating the patient. [See the American Medical Association's "Principles of Medical Ethics," on the AMA Web site, www.ama-assn.org.]

Likewise, patients are to refrain from asking the doctor to be dishonest or unethical; and if they do, the doctor must resist temptations to engage in unethical conduct with a conviction that to do otherwise will impair the patient’s recovery or best possible outcome. Moreover, patients are obligated to tell the doctor their fears and report when they have not taken the doctor's advice.

Doctors have the responsibility to avoid and interrupt potential conflicts of interest between their professional duty to their patients and their personal interests. This cornerstone of medical ethics justifies the physician's privileged access to very personal information about the patient's physical and mental condition, and permits the patient to trust that the physician will act in the patient's best interests. Only when people feel safe in a professional relationship can they entrust the doctor with their most private emotional, psychological and physical secrets.

Patients need to be aware of "red flags" that may indicate breaches of their doctor's professional duty to them. For example, when a doctor engages in a substantial outside business relationship or invites or has an intimate relationship with a patient, the doctor's emotional, personal or financial interests present a conflict of interest and impair his or her ability to provide optimal care. If a doctor is intoxicated or impaired when practicing medicine, he or she is violating medical ethics. Moreover, how the doctor is paid, by whom, and for what can skew the doctor's focus away from the patient's best interests—for example, if the doctor is rewarded for not seeing patients, gets bonuses for withholding care, or is paid extra for tests and procedures that he or she does not personally provide, supervise, or authorize.

Supporting and clarifying boundaries

Careful tending of a doctor-patient relationship by both the patient and the doctor will improve the quality of care the patient receives and flag inappropriate behavior. Rather than being barriers to care, healthy professional treatment boundaries greatly enhance the healing power of the doctor-patient relationship. Toward the goal of empowering patients and doctors to build and maintain healthy doctor-patient relationships, the sidebar gives some tips for patients and questions for them to ask their doctors and clinicians when improving their doctor-patient relationships.

There are times when doctors or patients should disqualify themselves from a relationship. Adhering to the principle of "once a patient, always a patient" preserves the clinician's role and fosters patient safety, independence, privacy, and autonomy. A prior intimate personal relationship with a patient presents ethical problems for the doctor, depending on the intensity, nature and duration of the relationship. Medical practitioners may engage in friendships with their patients, but caution always should be a guide when doctors and other clinicians consider treating a friend, just as most doctors do not treat family except in urgent circumstances. This is because their past and present personal involvement could cloud their professional judgment.

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