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Jason Chang, MD
R
emember pledging to practise medicine by that ancient and hallowed Hippocratic Oath at the beginning of medical school? Now, as we residents finish our formal academic training, we hone our physical examination skills, better acquaint ourselves prevention and treatment guidelines, and perform literature searches. We continue to learn what to do, but often deciding when and how to do these things invokes the art of medicine.As a second-year medical student (and because a beneficent friend coaxed me into it for a free trip to Toronto), I worked on a paper and presentation about the history of the Code of Ethics in Canada under the supervision of the always charming and colourful Dr Ian Carr, history of medicine Professor in Manitoba.
From the ancient Hippocratic Oath to Percival’s Medical Ethics to the Declaration of Geneva, these
statements acknowledge the power and sanctity invested in this art of medicine. Ethics in family prac- tice can range from prescribing Tylenol with Codeine No. 3 and Zithromax packs at the local walk-in clinic to dealing with delicate and difficult situations where patients request abortion or euthanasia.
Dr Melissa Mailhot, a second-year resident at Laval University in Quebec city, Que, provides an articulate perspective on the ethical issue of treating family mem- bers or close friends. The article actually offers high- lights of a paper, originally 30 pages long, for which she won the Nadine St-Pierre Award last spring.
Dr Chang is a second-year family medicine resident at the University of Alberta in Edmonton and is a member of the Editorial Advisory Board of Canadian Family Physician.
Residents are encouraged to e-mail questions, comments, per- sonal articles, and helpful information to [email protected].
(Note to third-year program directors and secretaries: please begin submitting information [contact names, e-mail addresses and website locators, phone numbers, fax numbers, deadlines, etc] for 2002 applications, as the end of April will be the dead- line for the annual July Residents’ Page article.)
Caring for our own families
Mélissa Mailhot, MD
I
n 1794, 2500 years after Hippocrates, Thomas Percival wrote a book entitled Medical Ethics.Percival was the first to address the issue of physi- cians treating family members. In Quebec, it was not until 1980 that the code of ethics1 of the Corporation professionnelle des médecins du Québec and the Quebec College of Physicians and Surgeons instructed phy- sicians to refrain from treating themselves, their spouses, or their children except in an emergency or in cases that were in no way serious. The American Medical Association’s Code of Medical Ethics2 stopped referring to this ethical issue in 1957. One of the few studies on physicians treating their own fami- lies was produced by LaPuma et al3 in 1991. LaPuma’s study found that this prac-
tice is commonplace.
Therapeutic relationships and their limits
The relationship between physicians and their patients
is unique. Physicians, not patients, are bound by a code of ethics. Moreover, physicians are responsible for the relationship. They must act in good faith, set boundaries, and set aside their personal agendas.
The limits, or boundaries, of the physician-patient relationship define the psychological and social dis- tance that physicians and patients expect to find and feel comfortable with. These limits are derived from ethical treatises, cultural mores, and jurisprudence.
It can be difficult to set clear boundaries, particularly when patients are family members. The result can be a conflict over roles, a poorly defined therapeutic rela- tionship, and even a trespassing of boundaries (which, in turn, can make it difficult to respect intimacy and
maintain objectivity).
When a physician treats a family member, a relation- ship characterized by empa- thy becomes a relationship characterized by sympathy.
Instead of simply understand- ing the patient’s situation, the
Residents’ page
546 Canadian Family Physician • Le Médecin de famille canadien VOL 48: MARCH • MARS 2002
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VOL 48: MARCH • MARS 2002 Canadian Family Physician • Le Médecin de famille canadien 547
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physician begins to identify with and feel what the patient is experiencing, sometimes very intensely. Objectivity goes out the window. It becomes difficult to step back and assess the situation. It becomes difficult to make appropriate, rational, neutral decisions that address the patient’s needs, not our own needs and insecurities.
Questionnaire and physical examination Family members might not want the intimacy that shar- ing their innermost feelings and secrets with a physician who is also a family member would bring. Consciously or unconsciously, either the physician or the patient might leave out important information. Intentionally or unin- tentionally, a patient could forget to mention aspects of previous medical or psychiatric treatment or emotional problems. When this happens, physicians miss relevant information that could inform, or even alter, the diagno- sis. Physicians could intentionally leave out the question- naire or elements of a physical examination, such as gynecologic examination, breast examination, or rectal examination, because this makes them uncomfortable and because they are unwilling to face such intimacy for personal reasons. Professionalism and neutrality give way to familiarity and false assumptions; the quality of medical care can suffer and become less than optimal.
Confidentiality
Confidentiality can be breached or compromised when a physician treats a family member, particularly when family ties are close. Confidentiality is harder to maintain within a family, especially when other family members insist on “knowing what’s going on.”
Compliance with treatment
Familiarity can lead to noncompliance. We are more likely to take advice seriously when it is delivered by a stranger than when it is delivered by a family member! Family and close friends might question the ability, methods, and even the skills of a physician they knew first as a daughter, son, niece, or friend. A patient who consults a physician who is not a relative has no preconceived notions; the physician’s state- ments and prescriptions are impartial and unbiased.
They are not complicated by a personal relationship.
Examples
Picture a family gathering where you are dancing with an aunt who suddenly decides to tell you about her chronic headaches. In your mind, you’re off duty. Not only that, you’ve just been having a heated discussion about politics
with your brother-in-law. You might respond to your aunt’s entreaty without thinking. You could even prescribe something without a moment’s thought to the underlying causes. Or, faced with a lack of information and no clinical preparation, and fearing that your aunt’s headaches have some organic cause, you might prescribe a battery of tests that are not indicated, even duplicating tests that have already been ordered by another physician. After all, if your aunt’s headaches are serious, you don’t want to be the one who missed the diagnosis! Neither response would be appropriate. You would have failed to take a full history (exploring the possibility of psychogenic causes) and to make a full examination (even if assessment were easy on the dance floor, a neurologic examination is neither appropriate nor practical under the circumstances, and few aunts would submit to such an examination in front of the whole family). Confidentiality would also be a problem, due to the physical circumstances and other family mem- bers present. There could also be a conflict of interest and a breach of your professional integrity.
Conclusion
It is important to remember that personal relation- ships, whether with family or friends, always jeopar- dize doctor-patient relationships. They make it difficult to maintain a relationship of empathy. Physicians’ emo- tional connection to patients who are family members also makes it difficult to maintain objectivity.
To provide high-quality care, we must avoid omis- sions, false assumptions, breaches of confidentiality, lack of objectivity, and unclear boundaries. When treating a family member, however, the risk of committing one of these errors is far greater than when treating others.
Becoming the physician of a family member or friend is unwise. In fact, the decision to set good boundaries and to refrain from becoming involved in the medical care of one’s family usually requires some soul searching. Even when refraining makes us feel powerless and out of con- trol, it is still the best way to really care for our families and to offer them our love, presence, and support.
Dr Mailhot is a second-year resident in family medicine at Laval University in Quebec city, Que.
References
1. Corporation professionnelle des médecins du Québec and the College of Physicians. Code of ethics. Quebec, Que: Corporation professionnelle des méde- cins du Quebec; 1980.
2. American Medical Association. Code of medical ethics. Chicago, Ill: American Medical Association; 1957.
3. LaPuma J, Stocking CB, La Voie D, Darling CA. When physicians treat mem- bers of their own families. Practices in a community hospital. N Engl J Med 1991;325(18):1290-4.
