pediatrics
August 1999, VOLUME104 /ISSUE 2

Appropriate Boundaries in the Pediatrician-Family-Patient Relationship

  1. Committee on Bioethics

Abstract

All professionals are concerned about maintaining the appropriate limits in their relationships with those they serve. Romantic and sexual involvement between physicians and patients is unacceptable. Pediatricians also must strive to maintain appropriate professional boundaries in their relationships with the family members of their patients. Pediatricians should avoid behavior that patients and parents might misunderstand as having sexual or inappropriate social meaning. The acceptance of gifts or nonmonetary compensation for medical services has the potential to affect adversely the professional relationship.

  • Abbreviation:
    AAP =
    American Academy of Pediatrics
  • Physicians and the public recognize the need for high moral standards and accountability in medicine. Most commonly, the focus of concern involves physician competence and integrity as demonstrated by such measures as board certification, hospital credentialing, peer review of practice, physician assistance programs, and malpractice litigation. Physician behavior is guided by various practice guidelines, review articles, policy statements by professional organizations, etc, as well as applicable law and regulations. Codes of ethics for physicians have a role in addressing personal and other nontechnical aspects of physician conduct, as exemplified by the American Medical Association's periodically updated code1and the 1997 document from the American College of Obstetricians and Gynecologists.2 The American Academy of Pediatrics (AAP) also has issued a policy entitled “The Use of Chaperones During the Physical Examination of the Pediatric Patient.”3

    This statement considers the appropriate professional boundaries between physicians who care for children, their patients, and the patients' family members. The AAP believes that physicians must exercise substantial care in nonprofessional relationships with patients and families to promote the highest possible degree of trust in the doctor-patient-family relationship.

    ROMANTIC AND SEXUAL RELATIONSHIPS

    It is difficult to find reliable data on the prevalence of sexual contact between physicians and their patients or their patients' family members. Position papers about psychiatrists4 and obstetricians5 comment on the lack of well-conducted reliable studies on professional boundary violations by physicians. Attention to the subject, in the form of complaints against practitioners and publications in professional journals, has been more prominent among psychiatrists and obstetrician-gynecologists.6–10 Interpersonal entanglements raise at least two serious questions. First, can a patient or family member make clear and free choices to accept or reject affections, especially sexual, in the context of the unavoidably unequal physician-patient-family relationship? Second, once such intimacy develops, can the parties maintain a proper and effective therapeutic relationship?

    Because pediatricians provide counseling services for patients and families, the concerns closely parallel those faced by mental health professionals. Pediatricians who feel sexually attracted to children may put patients at risk of sexual abuse or exploitation.11 More likely, however, pediatricians may be misunderstood when they first discuss sexual maturation and sexuality with patients.12 Similarly, examination of an adolescent's maturing genitals or breasts during an office visit may be distressing or misunderstood by the patient, especially if a parent or chaperone is not in the examining room.3 Pediatricians should develop and follow clear and consistent office policies about the presence of a chaperone during parts of the physical examination, taking into account local customs, families' religions and cultural traditions, and the need for patient privacy.

    Pediatricians also interact with the parents or guardians of their patients, although seldom in doctor-patient relationships. Pediatricians are responsible for maintaining appropriate professional boundaries with the families of their patients, although their obligations toward them may be somewhat different from those for their patients.

    There is an inherent risk of exploitation for patients or family members who depend on the knowledge and authority of the physician, especially in cases involving nonroutine health care. The success of the doctor-patient or doctor-parent relationship depends on the ability of the patient or family member to trust the physician completely. Patients and family members legitimately expect to feel physically and emotionally safe in professional relationships with physicians. They should not feel vulnerable to romantic or sexual advances while receiving medical care for themselves or their children. In addition, children should be free from concern that their treatment may be compromised by a nonprofessional relationship between a parent and their physician. Children should not have to worry about confidentiality or have anxiety over the potential for the physician to have a conflict of loyalty because of the physician's involvement with the parent.

    Patients or family members to some extent identify with and feel gratitude toward physicians. At times, these feelings may result in efforts to initiate a nonprofessional relationship with the physician or may leave the patient or family member consciously or otherwise unwilling or unable to reject a physician's romantic or sexual advances. Any confusion between complex professional bonds and extraprofessional personal relationships may leave the patient or family member unable to exercise the best judgment or choice about medical matters.

    The clinical judgment of physicians who become intimately involved with a patient or family member may become clouded and they may breach their professional responsibilities. Whether this possibility extends to close family members of patients is somewhat less clear. If the intimacy develops in the context of a patient's serious illness, concerns about exploitation of the family member's dependency on the physician arise. Under these circumstances, the physician is well-advised to end the professional relationship after ensuring the transfer of the patient's medical care to another appropriate practitioner. Nevertheless, proscriptions on physicians pursuing relationships with parents or adult siblings of their patients in unusual circumstances may result in unnecessary and inappropriate restrictions on the physician's personal life.

    INADVERTENT SEXUALITY IN THE PHYSICIAN-PATIENT RELATIONSHIP

    Physicians usually prefer warm, friendly relationships with their patients. The need to avoid untoward personal intimacy should not lead to a cold, indifferent manner in their interactions with patients or family members. Many cultures expect physical expressions of care and concern in times of personal crisis, including sickness. Physicians might well be seen as unsympathetic and excessively remote if they avoid handshakes or other socially approved touching during emotional encounters with families. In most social groups in the United States, interaction with children is likely to involve appropriate physical contact, such as hugging.

    Physicians should be aware of their patients' customs and personal and religious beliefs. In addition, it may be helpful to recognize that some kinds of touching may be confusing or offensive to children, depending on their stage of physical and emotional maturation. For example, certain children may have strong preferences about whether their physical examination is performed by a male or female physician, or whether someone else besides the physician is present during the examination. Anticipatory discussion of these issues should reduce fears and misunderstandings and lead to enhanced physician, patient, and family comfort.

    Physicians also have an obligation to recognize that physical interaction is not the only means by which humans communicate sexually. Body language and verbal expressions also convey attitudes and emotions that may provoke strong feelings. Because socioeconomic or cultural groups may differ in what they consider acceptable or expected behavior, it is usually best to ask patients and parents their preferences about how they would like to be addressed.10For example, pediatricians should use neutral language or names in addressing patients, rather than employing terms of endearment like “honey” or “dear.” Words that could be seen as evaluative or provocative when referring to body parts, such as the breasts, should be avoided.

    GIFTS OR OTHER EXPRESSIONS OF AFFECTION OR GRATITUDE

    Physicians may receive gifts from patients or parents, especially after providing help for an especially troubling health-related problem. Under most circumstances, gifts have a far more symbolic than material value.13 For most pediatricians, accepting modest gifts does not involve a serious conflict—in fact, refusal of a gift may constitute a social or cultural affront. As the monetary worth of the gift increases, however, so does the psychological and ethical difficulty in maintaining appropriate boundaries in the professional relationship. When the physician feels uncomfortable with a gift that a family insists on delivering, he or she should voice the concern, and suggest acceptable alternatives such as a charitable donation in the physician's name. Highly valued gifts may indicate that these boundaries have been crossed. The patient or loved one may have misinterpreted the physician's earlier behavior or may be inviting the physician to engage in a relationship that could compromise medical judgment and action.

    OTHER CONSIDERATIONS

    Patients or family members may want to compensate physicians with an exchange of services or with barter. For example, an adolescent or the adolescent's parents may offer the patient's services as a baby-sitter or gardener in lieu of monetary payment for care. Such arrangements vary legitimately with local custom and the economic circumstances of patients and families. However, problems may arise about exactly what services constitute adequate compensation for professional care and the appropriateness of increased personal contact between the patient or family member and the physician. Nonmonetary payments, as with gifts, may become precursors to boundary violations and should be approached with caution.

    RECOMMENDATIONS

    1. Physicians caring for children and adolescents need to be aware of the potential for conflict between their professional roles and their personal relations with their patients and their patients' family members. Romantic and/or sexual relationships with patients are always inappropriate. Romantic or sexual relationships with adult family members of patients should be avoided given the potential for adverse effects on professional judgment and family member behavior concerning the patient's health.

    2. Physicians caring for children and adolescents need to be aware that their words, body language, and other aspects of professional conduct may inadvertently offend or insult patients and family members. Many expressions and actions during the physical examination may have an unintended sexual connotation for the patient or parent. Physicians are advised to use neutral language that is acceptable to the patient and to discuss thoroughly and in advance aspects of care that may seem sexually charged.

    3. It may be appropriate for physicians to accept modest gifts from patients and their families. When the physician feels uncomfortable with a gift that a family insists on delivering, he or she should suggest acceptable alternatives such as a charitable donation in the physician's name. However, caution is urged when the material value of gifts or offered services could appear to influence the physician's professional judgment.

    4. Medical school, residency, and continuing medical education programs should routinely discuss the importance of personal boundaries between professionals, their patients, and their patients' family members.

    Committee on Bioethics, 1998–1999
    • Robert M. Nelson, MD, PhD, Chairperson

    • Jeffrey R. Botkin, MD, MPH

    • Marcia Levetown, MD

    • Kathryn L. Moseley, MD

    • John T. Truman, MD

    • Benjamin S. Wilfond, MD

    Liaison Representatives
    • Alessandra (Sandi) Kazura, MD

    •  American Academy of Child and Adolescent Psychiatry

    • Watson A. Bowes, Jr, MD

    •  American College of Obstetricians and Gynecologists

    • Ernest F. Krug III, MD

    •  American Board of Pediatrics

    Section Liaison
    • Donna A. Caniano, MD

    •  Section on Surgery

    • G. Kevin Donovan, MD, MLA

    •  Section on Bioethics

    Consultant
    • Joel E. Frader, MD

    Legal Consultant
    • Dena S. Davis, JD, PhD

    Footnotes

    • The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    REFERENCES