AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. May 2015, Volume 17, Number 5: 428-431.

Ethics Case

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A Friend’s Request for Treatment

Although the practice guidelines of several medical organizations recommend against treating friends or relatives, they make exceptions for emergencies or the unavailability of other qualified physicians.

Commentary by Horacio Hojman, MD

Peter and Tom have been best friends for more than a dozen years. Peter, a surgeon, is reputedly the best gastroenterological surgeon in the region. He is known for polyp resections, colectomies, and related surgical procedures of the gut. Tom teaches math at the county community college. They have been meeting to play golf at Peter’s golf club on the first Saturday of the month for many years. One Saturday, Tom approaches Peter with a look of concern, telling him that his last colonoscopy revealed a tumor and that he has to have surgery to resect part of his ascending colon. Peter listens intently. Then Tom says, “You’re the best colorectal surgeon around.”

Peter nods his head. “So they say.”

“Well, I know you don’t usually operate on your friends, but can’t you make an exception for me?”

Peter is slightly taken aback but remains silent. Tom continues, “It doesn’t seem to make sense for me to go to a ‘runner-up’ surgeon just because we happen to be friends.”

Commentary

The dilemma facing Peter is not uncommon. Almost all physicians, at one time or another, have been asked to provide care or advice for a relative or a friend. Sometimes the advice requested is for trivial medical conditions like a minor cut. But in other cases these requests can be particularly burdensome.

The American College of Physicians [1], the General Medical Council of Great Britain [2], and the Medical Council of New Zealand [3] advise against providing medical care to anyone with whom a physician has a close personal relationship. Similar recommendations have been issued by the American Academy of Pediatrics [4], the College of Physicians and Surgeons of Ontario [5], and the College of Physicians and Surgeons of British Columbia [6].

The American Medical Association (AMA) Code of Medical Ethics states: “Physicians generally should not treat themselves or members of their immediate families” [7]. Although these guidelines do not specifically mention friends, the reasons given for not treating family members apply equally to friends. First and foremost, patients deserve objectivity from their doctors. When a physician is emotionally involved with a patient, that physician’s objectivity can be called into question. Perhaps his friendship with Tom could cause Peter to overlook a potentially life-threatening complication or not to offer an objective and fair assessment of Tom’s clinical condition. Peter might be the best surgeon in town, but he might not be the best surgeon for Tom.

Even if Peter thinks he could treat Tom as if he were any other patient, humans are known to be self-deceiving when it comes to recognizing their own biases or limitations [8]. Peter might feel uncomfortable asking personal questions about Tom’s past medical history. Despite his eagerness to have Peter as his surgeon, Tom might also feel embarrassed about revealing certain confidential information or, worse, lie to him. One or both of them might feel uncomfortable about a complete physical exam and omit an important part of it.

If Peter and Tom are friends, most likely they know each other’s families. This shared personal knowledge could result in confidentiality and trust problems. If Tom chose to withhold certain information from his loved ones—for example, how serious his condition is—he might ask Peter not to reveal this information to his wife. Under normal circumstances, physicians can avoid disclosing information to family members by just invoking the patient’s right to privacy. This might be difficult for Peter, however, since Tom’s wife would most likely approach him as a trusted friend rather than merely Tom’s physician.

Furthermore, all surgical procedures, regardless of how experienced the surgeon is, can result in serious complications. Although obviously the consequences of one of those complications could be tragic for Tom, it could also have devastating emotional consequences for Peter.

Despite these concerns, there is scant information regarding their validity. Surveys indicate that physicians treat friends and family frequently [9-11]. Although doing so can cause physicians distress [11], it is unclear whether medical errors are more common when treating intimates. Many physicians could cite personal experiences of treating a family member or a friend in which their judgment was clouded by their emotional involvement. However, we tend to better recall experiences that confirm our fears, like a bad outcome, rather than uneventful ones that fail to confirm our fears [12].

Based on all the concerns expressed above, it would be prudent for Peter to politely decline to perform the surgery. He should tactfully explain his concerns to Tom. Perhaps he could offer to to be Tom’s advocate during the process and help Tom with finding another qualified surgeon to do his case and navigating the maze that health care can be [13]. Having major surgery can be a distressful and frightening experience, and the advice of a knowledgeable friend during this time can be invaluable.

However, all the guidelines mentioned above make exceptions for emergencies or when no other qualified physician is available. We do not know the size of the community where Peter and Tom live, the degree of access to other qualified surgeons within it, or Tom’s ability to access a surgeon outside it. Perhaps some of these options put a significant burden on Tom’s access to adequate care. If there is a reasonable cause that prevents Tom from accessing adequate care, Peter should agree to perform the surgery.



References

  1. American College of Physicians. Providing medical care to one’s self; persons with whom the physician has a prior, nonprofessional relationship; and VIPs. ACP Ethics Manual Sixth Edition. https://www.acponline.org/running_practice/ethics/manual/manual6th.htm#self-vips. Accessed March 26, 2015.
  2. General Medical Council. Good Medical Practice. Manchester, UK: General Medical Council; 2013:8. http://www.gmc-uk.org/static/documents/content/Good_medical_practice_-_English_0914.pdf. Accessed March 26, 2015.
  3. Medical Council of New Zealand. Statement on providing care to yourself and those close to you. June 2013. https://www.mcnz.org.nz/assets/News-and-Publications/Statements/Statement-on-providing-care-to-yourself-and-those-close-to-you.pdf. Accessed March 26, 2015.
  4. American Academy of Pediatrics Committee on Bioethics. Policy statement: pediatrician-family-patient-relationships: managing the boundaries. Pediatrics. 2009;124(6):1685-1688.
  5. College of Physicians and Surgeons of Ontario. Treating self and family members. February 2007. http://www.cpso.on.ca/CPSO/media/uploadedfiles/policies/policies
    /policyitems/treating_self.pdf?ext=.pdf. Accessed April 1, 2015.
  6. College of Physicians and Surgeons of British Columbia. Treating self, family members and those with whom you have a non-professional relationship. January 2013. https://www.cpsbc.ca/files/pdf/PSG-Treating-Self-and-Family-Members.pdf. Accessed April 1, 2015.
  7. American Medical Association. Opinion 8.19 Self-treatment or treatment of immediate family members. Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion819.page. Accessed March 27, 2015.
  8. Gold KJ, Goldman EB, Kamil LH, Walton S, Burdette TG, Moseley KL. No appointment necessary? Ethical challenges in treating friends and family. N Engl J Med. 2014;371(13):1254-1258.
  9. Walter JK, Lang CW, Ross LF. When physicians forego the doctor-patient relationship, should they elect to self-prescribe or curbside? An empirical and ethical analysis. J Med Ethics. 2010;36(1):19-23.
  10. Gendel MH, Brooks E, Early SR, et al. Self-prescribed and other informal care provided by physicians: scope, correlations and implications. J Med Ethics. 2012;38(5):294-298.
  11. La Puma J, Stocking CB, La Voie D, Darling CA. When physicians treat members of their own families. Practices in a community hospital. N Engl J Med. 1991;325(18):1290-1294.
  12. Gilovich T. How We Know What Isn’t So: The Fallibility of Human Reason in Everyday Life. New York, NY: The Free Press; 1991.
  13. Fromme EK. Requests for care from family members. Virtual Mentor. 2012;14(5):368-372.

Horacio Hojman, MD, is surgical director of the Surgical Intensive Care Unit and associate director of trauma surgery at Tufts Medical Center and an assistant professor at Tufts University School of Medicine in Boston. He is a member and the incoming chair of the hospital’s ethics committee.

Balancing Practice Policies with Patient Need, May 2015

Does Helping a Patient Find a Job Violate Professional Boundaries? May 2015

Doctor and Friend, June 2005

Requests for Care from Family Members, May 2012

The AMA Code of Medical Ethics’ Opinion on Physicians Treating Family Members, May 2012

The Overlapping Roles of the Rural Doctor, May 2011

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.