AMA Journal of Ethics^®

Case

Romantic relationships were common at Healer Hospital, and the administration’s lenience was a gesture of trust in the professionalism of its employees. After numerous complaints from patients, staff, and students about distracted patient care and favoritism, along with claims of gender-based discrimination and sexual harassment, the hospital administration met to discuss the possibility of new policy.

“We have received some very disturbing complaints about physicians showing favoritism to certain nurses, or nurses and physicians carrying on tense and destructive interactions following romantic relationships that went sour,” the hospital president, Dr. Rhodes, noted. “Such issues corrode collegial relationships and teamwork, and, ultimately, it’s the patients who suffer. That’s unacceptable if we are committed to putting patient care first, not to mention the morale of our employees and the standard of professionalism that we want to maintain.”

Dr. Rhodes suggested a zero-tolerance policy, meaning that no inter-staff dating or romantic relationships of any kind would be allowed among hospital personnel. He proposed penalties for those who violated the policy, including transfer from a department or even dismissal from the hospital.

Others at the meeting argued that such a policy would not stop romantic relationships but would only drive them underground, creating tension between employees forced to conceal their relationships and fellow workers deciding whether to protect them in violation of hospital policy or bring their relationships to the attention of administration. “We will be investigating possible relationships left and right,” opponents of the proposed policy said. “It will be a nightmare, and further undermine trust and teamwork among our employees!” They continued, “We will be punishing people for having relationships with each other—relationships that should be none of our business anyway!”

Dr Rhodes responded, “Their bad behavior makes it our business. Driving them underground protects our patients.”

Commentary 1

Healer Hospital is considering a zero-tolerance policy for physician-nurse relationships, which will presumably extend to physician-physician relationships and those between other hospital personnel. The workplace is frequently the site of consensual romantic relationships between adults. Television has gone to extremes in portraying relationships in hospital settings, oftentimes making the romance the central point of primetime “medical” dramas. Trysts occur in ambulances and hospital supply rooms; extramarital affairs are commonplace. Though these dramas exaggerate, they do demonstrate the range of problems that workplace relationships can create. Depending on the people involved and their roles, there may be favoritism in assigning cases or rotations or in promotion and advancement throughout training or employment. When a TV relationship goes sour, patient care is affected, spurned partners seek revenge, and their colleagues choose sides. Patient care becomes a distant second-place interest in such a drama.

It’s easy to understand how strong relationships can develop in hospitals. Staff work together under stressful circumstances and observe each other making decisions and acting in situations that critically affect patient outcomes. Working well together is satisfying, and respect for one another can grow to a friendship and then a romance. But the intense developing stages of a relationship can distract the romantic partners from patient care, and, if the relationship falls apart and becomes hostile, patient care suffers all the more.

So what sorts of ground rules can be put in place that recognize the inevitability of hospital relationships while informing workers of extremes that will invoke disciplinary action? Dr. Rhodes’ proposal doesn’t seem workable: staff members are adults, relationships will form, and a zero-tolerance policy will merely drive them underground. In a 2004 article in Journal of Medical Practice Management, attorney Bob Gregg described four types of policies concerning workplace romance [1].

1. The no-fraternization policy prohibits all romantic advances, overtures, and relationships by anyone in the organization. This model, consistent with Dr. Rhodes’ zero-tolerance policy, seems impractical on many levels. Does such a policy violate personal privacy? As Gregg points out, the First, Fourth, Fifth, and Fourteenth Amendments of the U.S. Constitution provide basis for privacy, free association, and equal protection against government intrusions into personal decisions concerning procreation, marriage, and family relationships. If the policy is so restrictive that constitutional rights are felt to be violated, employees could challenge it. Some courts have upheld an employer’s restrictions on romance as long as the restrictions were reasonable and did not intrude too far into the employee’s relationships with nonemployees. At the hospital level, forcing all relationships to become secret can cause healthy people acting in normal ways to feel immoral and guilty, which is bound to lead to overall weakening of staff morale, certainly not Dr. Rhodes’ intent.
2. A power model prohibits romantic overtures and advances in relationships where there is power asymmetry; that is, relationships in which one  person has authority over (or, in some places, is merely at a higher level than) the other person. If it becomes apparent that such a relationship exists, changes are made to ensure that the two parties are not working where one can affect the performance, rating, or promotion of the other. The power model would be very difficult to employ in the hospital where the structure of roles is so hierarchical. Nurses could have relationships only with other nurses at the same level. The same would be true for residents and attending physicians.
3. The third policy prohibits anyone from being part of a relationship in which one or both parties is married to someone else. Like policies one and two, this is difficult to enforce.
4. The fourth policy permits all consensual relationships, requiring only that the parties notify the organization, so it can confidently verify that the relationship is welcome and consensual. If one person is in a supervisory role, the company would want to assure that no job discrimination took place.

In addition to driving relationships underground, policies 1-3 introduce ethical dilemmas for those who are not in a prohibited relationship but become aware of it. Should co-workers remain loyal to the couple or to the hospital? Does the policy include sanctions for those who knew about the relationship and did not inform the administration? Must the administration investigate every bit of information about a relationship that comes to its attention?

After examining these options, Dr. Rhodes’ “zero-tolerance” policy is not one that I agree with. Consensual relationships should be allowed, but written policies against sexual harassment and discrimination must be in place and available to all employees, with methods for reporting and procedures for handling complaints clearly spelled out. Zero-tolerance is not necessary where and when adults understand what they are getting into, have seen the persons they are involved with under conditions of extreme duress, and are attracted to those individuals. Such experiences can be the bases for a stronger relationship, and it is difficult to hide such a relationship, especially when one is overworked and stressed. At the same time, it is important that relationship communication and affectionate displays take place outside the workplace. Particular care must be taken in today’s communication-rich work environment. In a 2003 petition of the Board of Commissioners of Arapahoe County, Circuit Court appeal, for example, it was found that 101 romantic and sexually explicit e-mail messages between a county clerk and a girlfriend were public record as they were sent and received on a work computer during work hours [2].