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Whilst having sexual relationships with current patients is clearly unethical, the ethics of such a relationship between a doctor and former patient is more debatable.In this review of the current evidence, based on major articles listed in Medline and Bioethicsline in the past 15 years, the argument is made here that such relationships are almost always unethical due to the persistence of transference, the unequal power distribution in the original doctor–patient relationship and the ethical implications that arise from both these factors especially with respect to the patient's autonomy and ability to consent, even when a former patient.Nor is love in the supermarket based upon a fiduciary relationship (see later discussion).In addition, ‘love transference' can be extremely capricious, often hiding a destructive hate transference that frighteningly erupts and engulfs the therapist and patient.Thirdly, a discussion of the role of autonomous choice and consent is presented.On the basis of this evidence, it is argued that the circumstances in which such relationships are ethically permissible are extremely limited and that official ‘sanctioning' of these relationships should be very much the exception, not the rule.Sexual misconduct usually commences with violations of more minor boundaries:“The road to therapist–patient sex is paved with progressive boundary violations.
The onus of responsibility for this last task falls on the person who has the most power in the relationship which, as I will argue, is always the doctor. the power that a physician possesses by virtue of her training in the discipline and the art or craft of medicine”. ' Despite having the Aesculapian power of a doctor, and the Social power of a hospital specialist, in addition to considerable Charismatic power (he was a well-liked and respected colleague), none of these were sufficient to counteract his lack of Hierarchical power by being a patient.
This is recognized within professional codes, for example by the New Zealand Medical Council which states that “the ethical doctor– patient relationship depends upon the doctor creating an environment of mutual respect and trust in which the patient can have confidence and safety”. It is an underlying principle of the concept of boundaries and it has been argued that it is the doctor's breach of fiduciary trust, not the patient's consent, which is the central issue regarding sexual misconduct. After 6 weeks in hospital, on the day of his planned discharge, he was accidentally given another patient's medication.
To create the necessary conditions of a safe, therapeutic haven for a patient, a strong fiduciary relationship has to be built. the personality characteristics of the physician independent of the disciplinary knowledge and skill that give rise to Aesculapian power”. Instead of receiving his azathioprine and corticosteroids, he was given a high dose of frusemide and captopril.
Many boundaries exist in the doctor–patient relationship.
These include boundaries of role, time, place and space, money, gifts and services, clothing, language and physical contact.
First, the concepts of boundaries and transference are discussed and a profile of the medical practitioner at risk of offending is drawn.