Wednesday, November 25, 2009

Doctor-Patient Sex: Why is it Unethical?

Earlier today I responded to the following anonymous response to a post I wrote in April about doctor-patient sex:
What is the actual harm to the patient? I have found countless articles and sites that claim dr. patient sex is "obviously harmful to the patient." Well, I am not a medical professional and not all the reasons are obvious to me. I am however somewhat of a victim in this sort of case (with a diagnostic consultant) and am trying to understand what happened. All I know is he gave me hope and then killed it through abandonment, etc. He made lots of promises and didn't keep them.

The comment got me thinking. To the best of my knowledge, every medical specialty in all of the countries whose medical ethics I'm familiar with finds doctor-patient sex unethical. But as the questioner noted, it's not clear what the basis of that ethical condemnation is.

I did some on line browsing in the literature and came upon an excellent article - "Arguments for Zero Tolerance of Sexual Contact between Doctors and Patients" - by R.M. Cullen, a GP in New Zealand.

Dr. Cullen examines four common justifications of the zero tolerance view of doctor-patient sex and finds them all inadequate to the task:

  1. Sex with patients is always harmful. Cullen points out that the evidence base for this conclusion is skimpy. There are no surveys of large numbers of patients who have had sex with their physicians to see how many have been harmed. What we have is powerful case reports of individual situations that were harmful to specific individuals. These don't prove that doctor-patient sex is inevitably harmful.

  2. Sex with patients always violates the principles that define an ethical sexual relationship: trust, equitable power balance, and consent. Cullen quotes a position paper by the College of Physicians of Ontario that concludes that because of the inevitable power imbalance between physician and patient, valid consent is never possible. But here too it is possible to imagine doctor-patient relationships that do not violate the principles.

  3. Sex with patients is always inconsistent with the virtues that characterize the ethical physician. Here Cullen cites an argument that to be ethical a physician must be self-effacing and self-sacrificing, and that these virtues rule out deriving sexual satisfaction with a patient. Once again Cullen concludes that we can imagine circumstances in which a self-effacing and self-sacrificing doctor falls in love with a patient and is loved in return.

  4. Finally, Cullen considers the argument that the intrinsic nature of medicine may forbid sexual contact with patients on an a priori basis. Edmund Pelligrino makes the strongest argument of this kind, in "Toward a Reconstruction of Medical Morality" and elsewhere. Pellegrino argues that three phenomena – the fact of illness, the act of profession, and the process of care – if understood properly, provide a coherent basis for professional ethics, including the prohibition of doctor-patent sex. But here, too, Cullen finds it possible to postulate examples that could evade this perspective.

Cullen's own argument for the zero tolerance position is simple and practical:

It first attempts establish that, as a matter of policy, sexual contact between doctors and patients ought to be prohibited. Then, [it asserts] that doctors have a moral obligation to comply with such a prohibition. If this is true then it follows, as a matter of definition, that doctors who have sexual contact with patients have behaved immorally.

[This] counterfactual argument may be summarised as:

Proposition. If sexual contact between doctors and patients were allowed then there would be unacceptable consequences.

Conclusion. Sexual contact between doctors and patients should not be allowed.

Cullen argues - in my view correctly - that it is not necessary to prove that every instance of doctor-patient sex will be harmful, contrary to principles and virtues, or inconsistent with the fundamental nature of medicine, to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero tolerance ethical stance based on (a) the potential for harm to the patient with (b) no offsetting potential benefits for the patient, combined with (c) the inevitable harm to trust in the medical profession itself, and via that loss of trust, loss of healing capacity.

Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.

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