Therapeutic Patient Relationship: Case Study

Ethics:
Therapeutic Patient Relationship

Training Session
By:

Michael R Rigda
Ohio University

2014
Table of Contents
Ethics:
Therapeutic Patient Relationships

Overview

Since the 1970s, ethics has been incorporated into virtually every aspect of the health care system. Because of such a small time window, the study of ethics in a medical perspective continues to change and improve for the benefit of the patient.

Studies of doctor-patient relationships indicate the need of greater ethical study and intervention. Studies show that although many physicians are aware that a romantic or sexual relationship is unethical, as many as nine percent believe that the ethics depends on the situation (Reese, 2012). Often,
an abuse in the doctor-patient relationship does not occur because of a lack in educational skills. Rather, abuse in the doctor/patient is attributed to flaws, or loopholes, in the rules of ethics and law (Subotsky et al, 2010). Continued research of the most recent ethical framework can begin lowering any chance of unprofessionalism. In order to have a successful patient relationship, a physician must understand and respect the barriers in place.

This session will take a look at ethics.
Participants will assess their own ethical principles and apply the concepts they’ve learned to problems in ethical communication and/or conduct in the workplace.

Behavioral Objectives

This session serves to provide six main purposes:

Intended to inform the physician on the definition of ethics
Clarify the nature of the ethical responsibilities held in common by current and prospective physicians.
Identifies ethical considerations relevant to physicians
Recognize different situations containing unethical conduct.
Gain the knowledge on how to respond to in situations that require ethical decision-making.
Apply the concept of good ethical behavior in their current practice.

Outline of Training Session

I. Introduction: What is ethics?

Ethics refers to a framework of discipline from a branch of philosophy, in which ideas of right and wrong, virtue and vice, and good and evil, are all examined systematically (Salovey & Meyer, 1990).

II. Components of Ethics

Participants will know basic history, definition, and examples of
ethics.

A. Ethical Framework – before we can manage ethical dilemmas in the health care setting, we must understand examples of ethical principle, as well as our own, to avoid any conflict of interest.

1. Self-Assessment
Culture
Values
Beliefs
Ideas
2. Continuous Regulation
Self-control
Trustworthiness
Professionalism
Education
Intervention

B. Understand the Significance of Ethics

1. Factors That Improve Ethical Conduct
a. Public view
b. Well educated individuals
c. School curriculum
d. Government regulations

2. Factors That Require Ethical Behavior
a. Provide company guideline for ethical behavior
b. Teach the company’s guidelines importance
c. Describe punishments for unethical conduct

C. Review Examples of Unethical/Ethical Conduct

IV. Class Activity – Ethics Assessment

V. Effectively practice effective ethical communication

A. Understand the needs of the recipient D. Ensuring the message considers the common good E. Continue to interpret for conflicts of interest

F. Consider the consequences of each message 1. Is this message mutually valuable?

2. Is this message violating confidentiality of another person?

3. Is this message questionable to your professionalism?

VI. Class Discussion

VII Summary of Training Session

VIII Conclusion

Literature Review: Where the Patient Relationship Ends

Dr A, a 49 year-old gynecologist, was treating a 36 year-old female patient, Ms B, for chronic vaginal yeast infections. He described her as being seductive during the appointments while also complaining the abusive relationship she had with her husband. Dr A found himself feeling very sympathetic towards her and began scheduling longer patient appointments so he could provide some ‘therapy’ for her as well as assessing and treating the vaginal complaints for which she ostensibly saw him. He would hold her hand while she talked about her difficult situation at home. This decent down the ‘slippery slope’ progressed into hugging, and then kissing at the end of the session. He recognized that he was feeling lonely and not having regular sexual relations with his wife. Dr A even noted that his wife was anorgasmic (as though her condition was in some way an excuse to progress to a sexual relation with the patient) (Gabbard & Hobday, 2012).

The first time that Dr A and Ms B had sexual relations was after hours in his office. This sexual encounter consisted of mutual oral sex. The meetings were set up during appointments in the office, usually at the end of the day. He finally ended these contacts when he felt the encounters were no longer gratifying to him. In addition, he was worried about being caught and that others would not understand his reasons for departing from the usual procedures (Gabbard & Hobday, 2012).

Following the filing of a complaint by the patient, Dr A was sent for evaluation. When asked directly he thought he had harmed the patient, Dr A responded that he felt he had actually helped her by his sexual involvement with her (Gabbard & Hobday, 2012).

Introduction
This physician, Dr A, failed to recognize the unethical conduct he was committing in the obvious power differential with the patient, Ms B. Dr A failed to recognize that a patient is paying for his expertise for the treatment of a disease or ailment, and not a relationship of conscious feelings. If Dr A had greater understanding regarding the ethical principle of the doctor/patient relationship, Dr A may have been able to make a more rational decision so this situation never occurred; likewise, if Ms B had more understanding of the ethical principle prior to her first appointment, Ms B may have had the knowledge to evade Dr A’s advances. In summary, the doctor and the patient should be educated on ethical conduct before the doctor-patient relationship is formed to avoid situations, like the example.

Studies show that although many physicians are aware that a romantic or sexual relationship is unethical, as many as nine percent believe that the ethics depends on the situation (Reese, 2012). The American Medical Association (AMA) states that prior doctor/patient relationships can influence the patient’s treatment and that such a relationship is unethical if the doctor “uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship” (American Code of Medical Ethics, 2012). The AMA’s use of “prior relationship” leaves wiggle room for the “it’s complicated” answer, which over one third of the physicians had answered to the question, “Is it acceptable to become involved reomantic or sexual relationship with a patient?” in Medscape’s 2012 ethics survey (Resse, 2012). Could it be that the physicians guilty of committing unethical conduct similar to the scenario about Dr A and Ms B are aware of the rules but chose in proceeding to break the barriers of the doctor/patient relationship because “it’s complicated?”

The “it’s complicated” answer may originate from feelings from the physician to do anything possible to treat the patient. One study on therapists, explains that the therapists would get sexually involved relationships with suicidal borderline patients in order to save the patient from suicide (Gabbard & Hobday, 2012). This ration is flawed, however, because the physician, like Dr A, should have continued to worked to retain the nature of the intended relationship as clearly therapeutic with any potential unexpected circumstances, which is the idea behind the entire therapeutic process (Crowe, Bewley & Subotsky, 2010). A professional needs to self-regulate their internal drives and thoughts in the absence of clear standards or unexpected circumstances, such as that of a suicidal patient whom is not responding to evidence-based treatment (Crowe, Bewley & Subotsky, 2010). This is critical because usually a patient will give up his or her own autonomy to respect the decision of a paternalistic physician (Asghari, Samadi, Rashidian, 2013). Not to say this approach to a doctor/patient is unethical, but it can leave room for unethical conduct if the physician cannot control his or her internal drives or thoughts.

Patients, like Miss B, need doctors that are competent in all areas of their profession. The study of ethics in undergraduate courses and medical school curriculum is still improving; consequently, it should continuously be assessed in terms of content, educational methods, and change in behavior, and be revised accordingly (Asghari, Samadi, Rashidian, 2013). Within only the past 20 years or so, medical schools have begun incorporating ethics as its own respective subject (Haughton, Sparke & Chukwudi, 2010). The introduction of ethics in to medical undergraduate curriculum has met resistance, however, because it is evolving constantly and some believe ethical topics are redundant or impossible to be taught (Haughton, Sparke & Chukwudi, 2010). Once a few generations of physicians are educated, they can begin teaching newer generations from first hand experience to ensure they are fully competent, rather than trainers teaching the instructors (Asghari, Samadi, Rashidian, 2013).

Ethics

Ethics, according to James S. O’Rourke (2003), “refers to a field of inquiry, or discipline, in which matters of right and wrong, good and evil, virtue and vice, are systemically examined (p. 49). Professional ethics is described by Craven & Hirnle (2009) as involving “principles and values universal application and standards of conduct to be upheld in all situations (p. 76).

The traditional principles that provided the moral grounding for the protection on human subjects in the United States began forming in the 1970s (Faden, Kass, Goodman, Pronovost, Tuins & Beauchamp, 2013). To this day, the main subject of ethical concern has been to protect patients from injury, risk, abuse, and unjust burdens of medical research (Faden, Kass, Goodman, Pronovost, Tuins & Beauchamp, 2013). There has been an importance in our society of forming a just health care system, which is guided by principles of healthcare ethics that include benefice, non-maleficence, respect for autonomy, and justice (Craven & Hirnle, 2008). Physicians, nurses, and other members of the health care team have been developing codes of ethics in order to sustain a just health care system.

Faden, Kass, Goodman, Pronovost, Tuins & Beauchamp (2013) propose a framework that consists of seven ethical obligations, they include:

1) to respect the rights and dignity of patients; 2) to respect the clinical judgment of clinicians; 3) to provide optimal care to each patient; 4) to avoid imposing nonclinical risks and burdens on patients; 5) to reduce health inequalities among populations; 6) to conduct responsible activities that foster learning from clinical care and clinical information; and 7) to contribute to the common purpose of improving and quality and value of clinical care and health systems (p. 4).

Most frameworks regarding medical ethics loosely follow these seven steps. Frameworks in ethics provide a systematic way to decide what’s right from wrong in a variety of assigned priorities that are goal emphasized (Craven & Hirnle, 2008). All members of the health care team have a framework, and they can find it resembles this model.

Several issues of unethical conduct in the health care setting can arise if ethical principle is ignored. The following are a few debated matters of medical ethical principle that occurs in the health care setting: physician-assisted suicide (Glover, 2010), clinical trials (Barton & Eggly, 2009), bribes/gifts from patients (Sah & Fugh-Berman, 2013), patient abuse, sexual comments/actions toward patient (Crowe, Bewley & Subotsky, 2010), confidentiality (Craven & Hirnle), and financial interests (Reed, Mueller, & Brennan, 2013). While some subjects such as euthanasia (physician-assisted suicide) may have different labels of good or bad from different people, other subjects such as sexual patient abuse is generally disfavored by most of society. While ethical principle of that society on certain principles might change at the about the same rate medical technology changes, it is still important for any health care worker to keep these principles in mind.

Since the implementation of medical ethics is relatively new, changes are rapidly occurring in medical education curriculum as well as the workforce. Evidence shows, the effects of the teaching of medical ethics causes greater ethical sensitivity in the clinical setting (Crowe, Bewley & Subotsky, 2010). However, there are still many cases in which medical ethics education does not have an impact. As the progression of ethics continues in the health care setting, evaluation of medical ethics teaching is vital. Research by Asghari, Samadi, and Rashidian (2013) finds that matching education to the needs of society is an important prerequisite to ensure that the education is successful, and not a waste of human or financial resources. The Institute of Medical Ethics recommends a pyramid of increasing levels of education, they include: knowledge, habituation, and action (Crowe, Bewley & Subotsky, 2010). The idea is to have medical students think critically about historical precedents and future situations involving ethical dilemmas, then put into practice the best consideration. The most important thing teaching ethics gives to medical students is awareness (Crowe, Bewley & Subotsky). With practicing physicians, it is important to continue education on professionalism because doing so shows its significance as a competency (Reed, Mueller, & Brennan, 2013). As introductory and continuing teaching methods are evaluated and improved, future medical students can become more ethically sensitive in their communication and actions.

References

AMA Code of Medical Ethics. Opinion 8.14 -- sexual misconduct in the practice of medicine. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion814.page Accessed November 3, 2012.

Asghari, F., Samadi A. & Rashidian, A. (2013). Medical ethics course for undergraduate medical students: A needs assessment study. Journal Of Medical Ethics & History Of Medicine, 6(1)
Barton, E., & Eggly, S. (2009) Ethical or unethical persuasion? The rhetoric of offers to participate in clinical trials. Written Communication, 26(3), 295-310

Craven, R.F. & Hirnle C.J. (2008). Fundamentals of nursing: Human health and function, 6th. Lippincott Williams & Wilkins Inc. Philadelphia, PA. 76-77.

Crowe, M., Bewley, S., & Subotsky F. (2010) Abuse of the doctor-patient relationship. London: Royal College of Psychiatrists.

Faden, R., Kass, N., Goodman, S., Pronovost, P., Tunis, S., & Beuchamp, T. (2013). An ethics framework for a learning health care system: A departure from traditional research ethics and clinical ethics. The Hastings Center Report, Spec NoS16-S27

Gabbard, G. O., & Hobday, G.S. (2012). A psychoanalystic perspective on ethics, self-deception and the corrupt physician. British Journal Of Psychotherapy, 28(2), 235-248.

Glover, P.C. (2010) Physician-assisted suicide is unethical. Greenhaven Press.

O 'Rourke, J.S. (2003). Communication ethics. Management Communication: A Case-Analysis Approach. 2nd. New Jersey: Pearson Education.

Reed, D. Mueller, P., Hafferty, F. & Brennan, M. (2013). Contemporary issues in medical professionalism challenges and opportunities. Minnesota Medicine, 96(11), 44-47

Reese, S. (2012). When is it okay to date a patient? Medscape ethics report 2012. Medscape, http://www.medscape.com/viewarticle/774295.

Sah, S. & Fugh-Berman, A (2013 Physicians under the influence: Social psychology and industry marketing strategies. Journal Of Law, Medicine & Ethics. 41(3), 665-672.

Attachment: Principles of Medical Ethics

Revised and adopted by the AMA House of Delegates
(June 17, 2001)

I.
A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements, which are contrary to the best interests of the patient.’

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard within the constraints of the law.

V. A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical
care

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

IX. A physician shall support access to medical care for all people.

Source: Code of Medical Ethics: In-Hand

Activity: Ethics Self-Assessment

The American College of Healthcare Executives (ACHE) made this survey so you can identify areas of ethical practice in which you are weak or strong. For each question, identify one of the five answers that is best suited to you. The ACHE does not believe in a numbered final score, because it is not a tool for evaluating ethical behavior of others. The number that corresponds with each response simply helps you uncover any areas of concern that may require the need for enhancement in some of your current ethical practice.

Almost Never Occasionally Usually Always Not Applicable 1 2 3 4 5

I. Leadership

I take courageous, consistent and appropriate management actions to overcome barriers to achieving my organization’s mission.

I place community/patient benefit over my personal gain.

I strive to be a role model for ethical behavior.

I work to ensure that decisions about access to care are based primarily on medical necessity, not only on the ability to pay.

My statements and actions are consistent with professional ethical standards, including the ACHE
Code of Ethics.

My statements and actions are honest even when circumstances would allow me to confuse the issues

I advocate ethical decision making by the board, management team and medical staff.

I use an ethical approach to conflict resolution.

I initiate and encourage discussion of the ethical aspects of management/financial issues.

I initiate and promote discussion of controversial issues affecting community/patient health (e.g., domestic and community violence and decisions near the end of life).

I promptly and candidly explain to internal and external stakeholders negative economic trends and encourage appropriate action.

I use my authority solely to fulfill my responsibilities and not for self-interest or to further the interests of family, friends or associates.

When an ethical conflict confronts my organization or me, I am successful in finding an effective resolution process and ensure it is followed.

I demonstrate respect for my colleagues, superiors and staff.

I demonstrate my organization’s vision, mission and value statements in my actions.

I make timely decisions rather than delaying them to avoid difficult or politically risky choices.

I seek the advice of the ethics committee when making ethically challenging decisions.

My personal expense reports are accurate and are only billed to a single organization.

I openly support establishing and monitoring internal mechanisms (e.g., an ethics committee or program) to support ethical decision making.

I thoughtfully consider decisions when making a promise on behalf of the organization to a person or a group of people.

II. Relationships

Community

I promote community health status improvement as a guiding goal of my organization and as a cornerstone of my efforts on behalf of my organization.

I personally devote time to developing solutions to community health problems.

I participate in and encourage my management team

to devote personal time to community service.

Patients and Their Families

I use a patient- and family-centered approach to patient care.

I am a patient advocate on both clinical and financial matters. I ensure equitable treatment of patients regardless of their socioeconomic status, ethnicity or payor category

I respect the practices and customs of a diverse patient population while maintaining the organization’s mission.

I demonstrate through organizational policies and personal actions that overtreatment and undertreatment of patients are unacceptable.

I protect patients’ rights to autonomy through access to full, accurate information about their illnesses, treatment options and related costs and benefits.

I promote a patient’s right to privacy, including medical record confidentiality, and do not tolerate breaches of this confidentiality.

Board

I have a routine system in place for board members to make full disclosure and reveal potential conflicts of interest.

I ensure that reports to the board, my own or others’, appropriately convey risks of decisions or proposed projects.

I work to keep the board focused on ethical issues of importance to the organization, community and other stakeholders.

I keep the board appropriately informed of patient safety and quality indicators.

I promote board discussion of resource allocation

issues, particularly those where organizational and community interests may appear to be incompatible.

I keep the board appropriately informed about issues of alleged financial malfeasance, clinical malpractice and potential litigious situations involving employees.

Colleagues and Staff

I foster discussions about ethical concerns when they arise.

I maintain confidences entrusted to me.

I demonstrate through personal actions and organizational policies zero tolerance for any form of staff harassment.

I encourage discussions about and advocate for the implementation of the organization’s code of ethics and value statements.

I fulfill the promises I make.

I am respectful of views different from mine.

I am respectful of individuals who differ from me in ethnicity, gender, education or job position.

I convey negative news promptly and openly, not allowing employees or others to be misled

I expect and hold staff accountable for adherence to our organization’s ethical standards
(e.g., performance reviews).

I demonstrate that incompetent supervision is not tolerated and make timely decisions regarding marginally performing managers.

I ensure adherence to ethics-related policies and practices affecting patients and staff.

I am sensitive to employees who have ethical concerns

and facilitate resolution of these concerns

I encourage the use of organizational mechanisms
(e.g., an ethics committee or program) and other ethics resources to address ethical issues.

I act quickly and decisively when employees are not treated fairly in their relationships with other employees.

I assign staff only to official duties and do not ask them to assist me with work on behalf of my family, friends or associates.

I hold all staff and clinical/business partners accountable for compliance with professional standards, including ethical behavior.

Clinicians

When problems arise with clinical care, I ensure that the problems receive prompt attention and resolution by there responsible parties.

I insist that my organization’s clinical practice guidelines are consistent with our vision, mission, value statements and ethical standards of practice.

When practice variations in care suggest quality of care is at stake, I encourage timely actions that serve patients’ interests.

I insist that participating clinicians and staff live up to the terms of managed care contracts.

I encourage clinicians to access ethics resources when ethical conflicts occur.

I encourage resource allocation that is equitable, is based on clinical needs and appropriately balances patient needs and organizational/clinical resources.

I expeditiously and forthrightly deal with impaired clinicians and take necessary action when I believe a clinician is not competent to perform his/her clinical duties.

I expect and hold clinicians accountable for adhering

to their professional and the organization’s ethical practices. Buyers, Payors and Suppliers

I negotiate and expect my management team to negotiate in good faith.

I am mindful of the importance of avoiding even the appearance of wrongdoing, conflict of interest, or interference with free competition.

I personally disclose and expect board members, staff members and clinicians to disclose any possible conflicts of interest before pursuing or entering into relationships with potential business partners.

I promote familiarity and compliance with organizational policies governing relationships with buyers, payors and suppliers.

I set an example for others in my organization by not accepting personal gifts from suppliers.

Source: American College of Healthcare Executives. Ethics Self-Assessment. http://www.ache.org/newclub/career/Ethics_self-assessment.pdf