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By Invitation

A violation of doctor-patient trust

Why sexual relationships, even if consensual, are wrong

In F. Scott Fitzgerald's last novel, Tender Is The Night, which was published in 1934, the protagonist is an American psychiatrist named Dick Diver. At the start of the story, Diver is at the cusp of what should have been a brilliant career. As the narrative unfolds, we see Diver taking on the case of a rich and beautiful but deeply troubled heiress who he not only treated but married as well.

His life subsequently unravels like a runaway skein, and by the end of the novel he is divorced and estranged from his children, and a drunkard whose career is in tatters. Had it been set in the present time, things might have turned out differently for Diver as he would have been in breach of professional conduct by marrying someone who was his patient and hence risked being sanctioned and possibly disbarred from practising as a psychiatrist.

The present position of the American Psychiatric Association is unequivocally clear: Sexual relationships with current or former patients are simply unethical and forbidden.

Very recently and in real life, a number of the British broadsheets have reported that the psychiatrist brother of the Chancellor of the Exchequer has been struck off the medical register by the British General Medical Council for an affair with a patient.

There are some who might not see anything wrong with such a relationship as long as it is consensual. This is premised on the proposition that sex between consenting adults should be a private matter and other people and society have no right to interfere, religious prohibitions notwithstanding. It might be further argued that it is demeaning, condescending and paternalistic to see patients as being so vulnerable that they cannot make their own decisions about their private lives, no matter how ill-advised those decisions might be.

ZERO TOLERANCE

However, almost all medical professional bodies around the world take the contrary view and see it as an absolute wrong. Most have stated this categorically in their code of ethics or conduct. Similarly, the Singapore Medical Council's Ethical Code and Ethical Guidelines state: "A doctor must not have a sexual relationship with a patient. This is to preserve the absolute confidence and trust of a doctor-patient relationship."


ST ILLUSTRATION: MIEL

This proscription goes all the way back to ancient Greek physician Hippocrates, who is widely acknowledged as the father of medicine. "With purity and with holiness, I will pass my life and practise my art... Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves," he was supposed to have said. The essence of that statement has since been enshrined in the Hippocratic Oath, which is sworn by many graduating doctors.

The zero tolerance for any sexual relationship between a doctor and a patient is based on a number of counts.

The defining characteristic of the doctor-patient relationship is its fiduciary nature (the word is derived from the Latin word "fidere", to trust). It essentially means that the doctor is entrusted by the patient to act in good faith, to behave professionally and to put the interest of the patient first. By having sex with a patient, the doctor is placing his own need over that of the patient who is exploited as an object of gratification.

Important as they are, professional codes of conduct and licensing boards, with their power of professional censure, are inadequate protection. What is important too is the cultivation of certain traits in the character of the doctor: honesty, integrity, the capacity for self-reflection and self-scrutiny, and to be fully aware of one's vulnerability.

For most of these patients, there is also that sense of betrayal and the expected loss of faith in their doctors and, by extension, in the medical profession as a whole. Besmirched and mistrusted, the medical profession will lose its capacity to heal and its respected position in society. And the patient is inevitably harmed. Although there are no comprehensive surveys to quantify the extent of this harm, there are numerous anecdotal accounts. These tell - often harrowingly - of the emotional impact on the patients: the confusion, anger, shame, guilt, depression that it induced and even precipitating suicide.

ASYMMETRICAL RELATIONSHIP

The doctor-patient relationship is naturally asymmetrical, with the balance of power greatly skewed towards the doctor with his expert knowledge, skill and experience, and status. The patient, on the other hand, is often in the role of a distressed supplicant who seeks relief, if not a cure. The patient can often be fearful of the doctor and might even idealise him. In such a situation and with such undercurrents of emotions - or, as P.D. James wrote in one of her crime novels, "arrogance and patronage on one side and weakness, gratitude and dependence on the other being no foundation for a satisfactory adult relationship, however transitory" - it is often argued that the sexual act should it happen cannot be truly consensual, not with such an imbalance of power and the likelihood of coercion and exploitation.

In a clinical encounter, doctors often need to ask patients personal and intimate questions. They also carry out physical examination of patients, who may be in varying states of undress. All this must take place in a safe and private environment and with the understanding that the interaction takes place within the confines or boundary of a professional relationship. This professional boundary is the edge of acceptable and appropriate behaviour - the parameters of professional conduct if you like. When that boundary is "violated", it implies that the doctor has transgressed and misused the position of trust and authority for his own pleasure or benefit.

Most sexual involvements of doctors with their patients are the culmination of a series of seemingly innocuous actions - a series of forays beyond the outer reaches of the boundary that one day goes down that slippery slope. It usually starts with an initial attraction to a patient (or an overwhelming urge to help the patient; "to love the patient back to health", was how one therapist said it) that leads to extending the clinical consult a bit longer than necessary. The subsequent clinical consults become increasingly more of a social interaction, the doctor starts to reveal personal details of himself, and thereafter with one thing leading on to another.

It might be tempting to see such problems as aberrations - that such acts are perpetrated by a handful of sociopathic doctors who prey on their patients. In which case, what is required is for the medical profession and society at large to identify these errant individuals and remove their licence to practise medicine.

However, this stance carries a certain risk. It might lull the majority of doctors into a sense of complacency that absolves them from monitoring themselves. A safer approach is to assume that no doctor is immune from such transgressions.

Of course, the vast majority of doctors do not go that way. Those who are more vulnerable to go slithering down this slippery slope tend to have some personal problems such as marital discord, bereavement, professional difficulties or some other unmet emotional needs.

The reality is that doctors do like certain patients more than others for a number of reasons, and patients too can feel attracted to their doctors. The human interaction between a patient and a doctor is more complicated and nuanced than both might be aware of - it can even be treacherous. What doctor and patient might think initially as a safe and pleasurable interaction could be the camouflage of an enemy who works in apparent concern and affection.

Important as they are, professional codes of conduct and licensing boards, with their power of professional censure, are inadequate protection. What is important too is the cultivation of certain traits in the character of the doctor: honesty, integrity, the capacity for self-reflection and self-scrutiny, and to be fully aware of one's vulnerability.

Fitzgerald's Dick Diver yearned to be "good... kind... brave and wise" but he also "wanted to be loved, too, if he could fit it in". It is human to have needs and we often have strong urges to fulfil these needs. Writing on this matter, the American psychiatrist Glen Gabbard noted that doctors should pay attention to their own self-care and be sure that their own personal lives are reasonably satisfying so that they not seek emotional gratification from their patients. "A lifeguard cannot save a drowning man if he himself is drowning," he cautioned.


•The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.

A version of this article appeared in the print edition of The Straits Times on May 21, 2016, with the headline 'A violation of doctor-patient trust'. Print Edition | Subscribe