Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether to report a retired psychiatrist alleged to have dated patients?
Should a doctor report a patient's allegations to the state medical board, despite her insistence that he not do so?
Yes: 51%
No: 49%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his book, :
Ethical norms and many state laws prohibit sexual relationships between healthcare providers and their patients. For instance, California bans marital and family therapists from having such relationships until two years after treatment has ceased. The American Psychological Association's ethics code similarly forbids relationships between psychologists and patients for at least two years after their last professional contact -- and even then, such relationships are permitted only under the "most unusual circumstances" where the psychologist can establish that there has been no exploitation.
The rules governing psychiatrists in the U.S. are even more stringent: they may never have sexual relationships with people they have treated. States have refused to carve out exceptions, even for providers who marry patients long after treatment has terminated.
The argument for such a blanket rule is that such relationships inherently "mismanage the transference" between doctor and patient -- a fancy way of saying that, even after psychotherapy ceases, doctor and patient are never equals.
Rules governing psychiatrist-patient sex were far more fluid until the 1970s. Many prominent figures in the psychiatric field, including Carl Jung and Bruno Bettelheim, are alleged to have had affairs with their patients; a 1972 study found that 10% of Los Angeles psychiatrists admitted to sexual relations with individuals under their care.
The American Psychiatric Association did not formally prohibit such relationships until 1973. Only with the case of Roy v. Hartogs in 1975 (later the basis for a TV movie "Betrayal," starring Rip Torn and Lesley Ann Warren) did the profession fully turn against doctors like Renatus Hartogs, who was accused of using his office as a pickup lounge.
Yet such conduct did not end then: former APA president Jules Masserman was sued in the 1980s by four former patients for sexual misconduct; psychiatrist Jack Gorman, president of Harvard's McLean Hospital, surrendered his license in 2007 following such an affair.
Most psychiatrists and ethicists now view therapist-patient sex as unethical -- although some disagreement remains regarding relationships with former patients pursued after a lengthy passage of time. The issue of romantic relationships with the close relatives of patients has also become a concern, with at least one state medical board penalizing the practice. Most states require physicians to report knowledge of the misconduct of colleagues; much of the time, if one discovers a fellow psychiatrist is sleeping with a patient, one has a moral obligation to report that transgressor to the state.
Yet the situation is more difficult in cases such as our hypothetical, where patient Rita tells her new psychiatrist, Stockmann, about her earlier relationship with therapist Praetorius, and her suspicions that he had such relationships with other patients. Rita has no proof of these subsequent relationships, however, and she actively discourages Stockmann from taking any action.
Physicians have considerable leeway in breaching confidentiality to prevent serious future dangers to the health or safety of others. If Praetorius were still treating patients, Stockmann might face a difficult task of determining whether protecting the public from his renegade (but now retired) colleague would justify the damage he might cause to his therapeutic relationship with Rita. As Praetorius is not actively engaged in patient care anymore, however, the risk to the public appears much lower. (Of course, Praetorius might still return to practice someday.)
Under such circumstances, most -- but not all -- ethicists would argue against divulging Rita's secret. At the same time, Stockmann may wish to work with his patient to persuade her to take the matter to the licensing board on her own, an act which might both serve justice and prove therapeutic.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Refuse Treatment for Dictator?