A neurosurgeon removes a benign brain tumour for a young family man. The patient requires MRI follow-up so they see each other every six months for awhile, and then every year. Subsequently, one or two more treatments of the tumour are required. The patient wishes to get active in fund-raising at the neurosurgeon’s hospital. This requires frequent e-mails and phone chats and one or two lunch meetings. They find they have much in common in spite of their 20-year age difference. Then they start to arrange lunches and dinners out on a semi-regular basis, taking turns picking up the tab. Conversations go back and forth between work issues and personal lives. They ultimately share fairly intimate stories and feel comfortable doing so. After eight years, they find they are friends. The patient will require ongoing monitoring and may need more surgery down the road.
A challenge of ethics?
Irrespective of whether you’re a surgeon, family doctor, internist, or whatever type of physician, think of when something like this happened to you. Is this scenario acceptable or does it give you a queasy feeling in the pit of your stomach? Very little has been written about the ethical challenges related to doctors developing friendships with their patients. It must happen most commonly with family physicians, who have a large volume of patients and frequent contact with many. One commentary article suggests rough guidelines for physicians considering taking on an existing friend as a patient and the Canadian Medical Association Code of Ethics suggests that medical treatment of family should consist of emergency care only, but it doesn’t address the issue of taking on friends as patients. Nor does the American Medical Association Code of Ethics. Clearly, the best approach to this would seem to be prophylaxis — don’t take a friend on as a patient if there’s any alternative available, which there almost always will be, except perhaps in a small town.
But what about when a friendship develops between a doctor and his or her patient over time — something neither may have much control over, as interpersonal chemistry is an aspect of human behaviour that isn’t amenable to prophylaxis or treatment? Patients and physicians are people, and when people are thrown together — irrespective of circumstance — commonalities are found, opinions formed, and bonds of attraction created. There’s not a physician who hasn’t studied his clinic list for the next day, stopped at one of the names and said to himself something like: “Mr. L. — what a neat guy, and so dignified and courageous. I wonder where he gets his strength. And he’s a dog lover too. I really like that guy.” If these feelings exist and conditions and/or shared interests arise that bring the doctor and his patient together outside the clinic, the seed of a friendship has been planted. Time and various forms of nourishment will enable its growth.
Not black and white
I could find nothing on this topic in the medical literature, but The College of Physicians and Surgeons of Ontario does provide some loose suggestions culminating in: “in certain circumstances it may be prudent for the physician to stop providing care to the individual.” There are definitely some guidelines for physicians finding themselves at the other end of patient-physician compatibility spectrum.
The ethical concern when this occurs certainly relates to a potential conflict of interest and/or loss of objectivity on the part of the physician, which could compromise his medical care of the patient. Should doctors never allow this situation to arise and/or recuse themselves from being the patient’s physician immediately if it does? It’s clear that sexual relationships or relationships involving love should not exist between patient and physician. If a doctor were to find him or herself in this situation they would either have to keep their secret feelings inside or, if they wished to act on them immediately, recuse themselves from the physician-patient role and find the patient another doctor. Medical societies and colleges have unambiguous guidelines about this form of misconduct by physicians, and they’re widely understood. But the challenge of treating a patient who has become a friend is less obvious and clearly less of an egregious breach of boundaries than a sexual relationship, and colleges and other governing bodies address this scenario only in generic terms, if at all. The overarching conundrum at play is embodied within the question that every physician in this situation must ask himself: “Am I prepared to say or do things in the best medical care of this patient that I would do if this person were not a friend?” If the answer is “yes” then I humbly submit there’s nothing morally wrong about a physician becoming friends with a patient.
In the case above, the physician had a conversation with the patient, bringing the issues into the open and asking him if he was comfortable with the situation. “I do see what you mean. For now I’m fine if you are. If we get too close, I will let you find me a new brain surgeon,” was his intelligent response.
Mark Bernstein, MD, FRCSC is a neurosurgeon at Toronto Western Hospital, with a strong interest in bioethics.