Patient-Provider Relationships and Professional Ethics


Prof. Shimshon Rubin, Chairman of the Clinical Psychology Program and of the Postgraduate Psychotherapy Program in the Department of Psychology, here discusses a subject that occasionally makes for sensationalist newspaper headlines in Israel and abroad. He makes these observations, he says, “as a professional, a teacher, a researcher, and a consumer of services.”

Articles in the Israeli press describing physicians and psychologists who have been sexually involved with current patients are part of a trend toward looking at professional ethics that is redefining the meeting point between professionals and their clients/patients/consumers.

Myth: The relationship between doctor and patient is an issue of individual rights; as in other relationships, it is a matter of consent between two adults.

Fact. The relations between professionals and clients are considered to be a matter that goes beyond a matter of individual rights and discussion.

The sexual mores of health-care professionals and patients do not occur in a vacuum. The belief in the general rights of individuals to decide their own fate is an important aspect of the Weltanschauung of the U.S. and becoming increasingly so in Israel. Nonetheless, it would be mistaken to conclude that the consensus of opinion on this matter is in favor of “an individual’s right to decide.” Other factors take precedence.

The professions are entrusted by society and the law to regulate the behavior of their members as part of the social contract that allows them special privileges and special tasks in self-regulation. Among these tasks are licensing and ethics regulation, along with permission to engage in behavior typically not sanctioned to the general public (e.g. to operate on another person, to hear another’s most intimate secrets, to be with a stranger who is unclothed, etc.) As part of the bargain, the rules of conduct for these professions are also defined: e.g., keeping professional secrecy, not taking sexual or financial advantage, maintaining expertise, etc.

Myth: All know and agree that sexual relations between health-care providers and patients are wrong and not to be tolerated.

Fact: Many professionals and members of the public have a complex (if misinformed) picture that suggests that they are willing to make allowances for “love” and other extenuating circumstances, depending on who initiated the contact and whether the patient is still formally in treatment, etc.

An Israeli study that I conducted with Omer Dror, and that is being published in the Hebrew language Psychology, documented that non-psychiatric physicians and clinical psychologists in Israel viewed patient-provider sex more leniently when it occurred in the context of “true love.” High percentages believe that relationships with clients after the “termination” of treatment was acceptable. An earlier version of the research was published in Ethics and Behavior and is available on the Internet (http://psy.haifa.ac.il/~rubin/APRETH96.html).

Further research, with Dana Amir, that at this writing is being prepared for publication demonstrated that both non-professionals and clinical psychologists in Israel are mixed in their ratings of and referrals to therapists who have had sexual relations with patients. The general public is quite lenient on the issue and may not be informed of the seriousness of this behavior.

Myth: Health-care professional ethics that include specific prohibitions against patient-provider sexual activity in their ethics codes do harm to their profession because specific reference to sexual activity (a) is unnecessary; (b) is an embarrassment to the profession; (c) undermines the trust between professionals and their patients; (d) does not deter the people who would do it anyway; and (e) is not supported by research.

Fact: All of these reasons have been discredited.

It is true that the Hippocratic oath prohibits sexual relations between physicians and their patients, but this is insufficient. The ethics codes of today’s health-care provider professions are more specific; they are considered to provide an expected standard of care for which violators can be penalized by professional and legal authorities.

Specific prohibitions against patient-provider sexual relations were not inserted into the ethical codes of the health-care professions in the U.S. until the 1970’s. In Israel, they began coming on line in the 1990’s. Likewise, education on the subject and discussion with Israeli professionals in training are necessary, but still slow in coming.

The shift in attitudes toward this area occurred because of a number of factors, including survey research that showed that the problem was real. Research on the unequivocal nature of the harm that occurred to patients were consistent and made clear that this activity was harmful to the vast majority of patients studied. It is an interesting fact that the professionals who engage in this activity inevitably regret the behavior because of the negative impact that it had on themselves, with no concern for the clients.

Myth: In general, it is moralizing (sexually repressed?) “preachers” and/or hypocrites who are involved in considering the branch of ethics concerned with provider-patient relationships.

Fact: A broad coalition of individuals in medicine, religion, law, philosophy, psychology, and other disciplines have worked to define and consider the range of issues involved in bio-ethics that touch on fundamental issues of the protection of patients and respect for human rights.

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