Medics probe boundaries of doctor-patient relationship

It doesn't take a medical ethics board to conclude that a doctor having sex with a patient violates the trusted physician-patient relationship.

But what about other, less extreme behavior? Does seductive language constitute an ethical infraction? Can a physician treat the accountant who prepares his taxes? Can a doctor hug a patient at the end of a visit?

Harvard psychiatrist Dr. Carol Nadelson explored boundaries in the doctor-patient relationship, and who might be most likely to cross them, at a session of the 10th annual International Conference on Jewish Medical Ethics last weekend. More than 400 attended the four-day conference, co-sponsored by the San Francisco Hebrew Academy.

Tzvi Hersh Weinreb, a congregational rabbi and psychotherapist in Baltimore, added a Jewish ethical perspective to the discussion at the Park Plaza Hotel in Burlingame.

The question "Who am I?" is paramount, the rabbi said. "Often the answer determines what is right. Out of the answer should come ethical guidelines."

He asked those attending the conference session to answer the question "Who am I?" 10 times in writing. People jotted down answers ranging from personality traits to nouns such as "father" and "daughter."

"If one of the answers was `physician,' that means you have a higher standard, a different standard than other people," Weinreb said. "I stand in a tradition of physicians going back to Hippocrates, to Maimonides."

Nadelson's overview made it clear that a discussion of doctor-patient boundaries comprises a broad rubric. "We have a spectrum that requires judgment and careful thinking," she said.

"An essential component of professional conduct is respect for the patient's dignity," she added. "This includes the physician's language."

Violations can be major or minor, she pointed out, ranging from the most extreme cases of sexual assault to the giving or accepting of certain kinds of gifts.

Even "calling a patient by their first name without asking for permission can be a problem."

In cases involving sexual contact, doctors are often clinically depressed or addicted to alcohol or drugs, said Nadelson, a professor of psychiatry at Harvard Medical School. Less often, they suffer from character pathologies, such as narcissism or paranoia.

As for the patients involved, "there is no one profile," she said. "Regardless of any patient provocation, it's always the doctor's responsibility." However, patients are likely to share common aftershocks: a sense of betrayal, abandonment, shame and guilt.

In assessing possible boundary violations, Nadelson stressed the importance of context. While taking a routine medical history, a doctor may ask a question perceived by a patient as offensive or irrelevant.

For that reason, she said, "it's terribly important" that physicians explain why they're asking a given question.

Similarly, a friendly or comforting hug may be uncomfortable for certain patients. "Those with histories of sexual abuse may experience a hug or a kiss as an assault, a repeat of early boundary violations," she said.

Like Nadelson, Weinreb considered the question of boundary violations in a broad context.

"I have seen sexual transgressions, but there are others for sure," he said. Among them is the failure to respect cultural diversity.

For example, Weinreb has been asked to serve as an expert witness in a case against a prominent psychotherapist in his area. Several patients were outraged when, speaking of spiritual aridity in their lives, the doctor suggested spiritual paths, including Jews for Jesus.

Surprisingly, however, Weinreb pegged arrogance as "the worst boundary violation of all.

"A passage in the Talmud says, `I can't live in the same world as an arrogant person,'" he said. "A humble person knows full well who he is. On the heels of humility comes true piety, true devotion."

Leslie Katz

Leslie Katz is a former J. staff writer.