All doctors inevitably receive requests both big and small from family, friends and acquaintances in relation to medical advice and treatment. This article discusses the ethical, legal and medical aspects of such involvement, and suggests what issues to consider before accepting the role of treating physician.
Illustration: Stine Kaasa
Doctors possess sought-after competence on something that interests us more than anything else: our own health. For many people, having a doctor in the family or as a close friend provides extra reassurance, and most doctors have received questions about diagnoses or treatment in one form or another from their loved ones. Norwegian and international surveys show that approximately 99 % of doctors state that they have been asked for medical advice or treatment by family members, and 85–96 % have prescribed medication for these (1, 2).
Such requests can be relatively unproblematic, for example general advice on health, explanations of medical terms, consultations for some minor complaints, and assistance in finding where to seek medical advice. However, most doctors will also have to deal with requests that may entail greater ethical dilemmas – including examinations and diagnoses of more complex conditions, assessments of other doctors’ treatment, requests to prescribe prescription drugs and even to carry out surgical interventions. In such situations, the doctor may face a challenging ethical dilemma. On the one hand, a range of problematic ethical and moral aspects may arise when treating family and friends, and professional ethics guidelines therefore advise doctors against treating those with whom they have close personal relations (3, 4). On the other hand, such treatment can be both convenient and cost-effective, and perceived deficiencies in the health service may provide an incentive for the doctor to intervene. In addition, doctors, like everyone else, want to look after their loved ones as best they can.
In the following, I will highlight some key aspects that must be considered when doctors treat family and friends.
When assuming the role of a treating physician and advisor to people with whom you have close personal relations, it will be challenging to maintain the degree of clinical objectivity required to give optimal treatment. In this context, optimal treatment must be understood as ‘not too much and not too little’ – in other words, treatment that complies with the applicable guidelines and for which there would be professional consensus.
99 % of doctors state that they have been asked for medical advice or treatment by family members
The doctor’s personal feelings for the patient will easily colour her or his professional assessment and lead to either overtreatment or undertreatment. Fear of illness and a desire to provide excellent treatment may induce the doctor to make an unjustified treatment referral or diagnosis. Conversely, a strong focus on not favouring your family and friends may result in failing to perform services that another doctor would regard as professionally correct. The more emotionally involved the doctor is with the patient, the more difficult it can be to make sensible choices.
Personal privacy and intimacy
In a doctor/patient consultation where there are close personal relations, it can be difficult for both parties to broach sensitive issues such as sexuality and mental illness. The patient may keep quiet about these, and the doctor may hold back from asking about such matters. The same applies to intimate examinations – which can be particularly problematic if the patient is underage. Consequently, there is a risk of an incomplete examination, possibly resulting in misdiagnosis and wrong treatment.
When information on personal, private and health affairs is shared in both consultations and social contact, considerable challenges arise in respect of patient confidentiality. In practice, the degree of formality of a consultation with family and friends will tend to vary.
In some cases, the doctor will be asked for assistance with health problems in an informal setting. She/he may be tempted or feel pressured into giving advice, or carrying out simple diagnosis or treatment outside the formal setting of a GP consultation. In such situations, it is extremely easy for the doctor to do inferior work and make mistakes, and the risk of breaching patient confidentiality increases considerably. ‘The patient’ might also regard this as a GP consultation while the doctor feels that she or he has merely given informal advice.
The doctor’s personal feelings for the patient will easily colour her or his professional assessment and lead to either overtreatment or undertreatment
In this context, it is worth remembering the Norwegian Health Personnel Act’s definition of health care: ‘The term health care shall mean any act that has a preventive, diagnostic, therapeutic, health-preserving or rehabilitative objective and that is performed by health personnel.’ (5). The commentary on the wording of the Act also specifies that when health care is given, the services performed must be justifiable, and that health personnel must comply with the provisions of the Health Personnel Act regarding information, the duty to keep patient records etc. (6).
If health care is given in this informal manner and it later results in a negative outcome for the patient, the fact that nothing has been registered in the patient record will therefore pose considerable problems.
Autonomy and informed consent
Pursuant to section 4–1 of the Norwegian Patients’ Rights Act, health care can only be provided with the patient’s consent (7). A close relationship may make it difficult for the patient to reject the doctor’s proposed treatment. It may also make it difficult to ask the opinion of another doctor. A child’s patient autonomy will become particularly vulnerable in such a relationship, especially if the doctor is the child’s own mother or father.
In many cases, the doctor will expect the patient to have confidence in the assessments made because of their personal relationship. This expectation may result in the doctor failing to give appropriate information that will allow the patient to make independent choices on a well-informed basis. Not only may the patient’s autonomy be compromised in such situations but also that of the doctor. Several surveys have shown that many doctors who have been asked to treat family and friends or have performed such treatment may find this uncomfortable and ethically challenging (1, 2). A number of doctors in such situations have also felt pressured to carry out health care outside their own area of expertise, and have experienced a lack of objectivity and inadequate examination as a problem (2).
Relations with public bodies
If the doctor is to advocate for the patient vis-à-vis public bodies such as the Norwegian Labour and Welfare Administration (NAV), a family relationship will in practice disqualify the doctor. The same will apply if the doctor’s examinations or treatment are to be used by other health personnel as a basis for such contact. Such factors may not only affect the protection of patients’ rights but also the professional integrity of the doctor. For example, it can be difficult to claim that authorising the sickness absence of a close family member is completely unaffected by emotional ties.
In such situations, it is extremely easy for the doctor to do inferior work and make mistakes
If the doctor’s treatment or other intervention has a negative impact on a close relative, this is something both parties must live with in the future. It could potentially lead to irreparable damage to their personal relationship. If there are serious consequences, this may result in an application for patient injury compensation. Should this be the case, it is in the interest of all parties that all contact between doctor and patient is well documented and the relationship between them is as well-organised as possible without a large number of informal or semi-formal interactions. In a worst-case scenario, such relations may affect the outcome of a compensation case.
Asymmetric doctor–patient relationship
A doctor-patient relationship is per definition asymmetric, and this asymmetry is augmented by the fact that the doctor acquires detailed knowledge about the patient’s physical and mental health. Such asymmetry can therefore arise in the private relationship between doctors and their loved ones when the doctor adopts the role of their treating physician. Depending on the sensitivity of the information, this might affect the relationship between the parties in the foreseeable future. Many doctors have failed to reflect on this impact beforehand, leading to regret in retrospect (8).
Gatekeeper role and discrimination
The ‘gatekeeper’ role is an important part of the doctor’s practice. This means ensuring that patients receive appropriate treatment for their condition at the right time while avoiding overtreatment and overdiagnosis. Both health professionals and patients may wish to have examinations and treatment ‘just to be sure’, and in many cases emotional ties will lead to doctors increasing their use of ‘unnecessary’ interventions. Such overdiagnosis and overtreatment will increase the risk of adverse events, while perhaps also resulting in increased costs for a public health service that is already under financial pressure (9, 10).
It can be difficult to claim that authorising the sickness absence of a close family member is completely unaffected by emotional ties
Chapter 1, section 12 of the Norwegian Code of Ethics for Doctors states that:
‘A doctor shall in his or her practice have due regard for the national economy. Unnecessary or excessively costly methods must not be employed (…). A doctor must contribute to the distribution of medical resources in accordance with generally accepted ethical norms. A doctor must in no way seek to provide individual patients or groups with unjustified advantages, whether financial, in respect of priorities, or otherwise’ (11).
Even though treating family and friends may be convenient and in some cases also potentially cost effective, doctors may face an extremely challenging balancing act in ensuring that their own involvement does not result in unnecessary costs or discrimination. The problematic aspects of doctors’ private referral practices have also been highlighted by the Council for Medical Ethics in an article in the Journal of the Norwegian Medical Association (12).
Prior to treatment
When doctors are involved in the diagnosis or treatment of family or close friends, a dynamic tension arises between their personal and professional roles. Although professional ethical guidelines mainly advise against treating people with a close personal relationship to the doctor, an exception is made for emergency cases, when no other healthcare professional’s help is available or in the case of minor, insignificant conditions (3, 4). Nevertheless, if the doctor is considering whether to provide health care when asked by a close relative or friend, she/he is recommended to thoroughly consider the aspects discussed in this article before making any decision. La Puma et al. have suggested seven questions that health professionals should ask themselves when considering whether to give health care to their loved ones (Box 1) (13).
Box 1 Seven questions to consider before providing treatment to family or friends. Based on La Puma et al. (13).
Am I sufficiently trained in this field to meet the patient’s medical needs?
Am I too close to probe the patient’s intimate history and examine her/him – and to cope with being the bearer of bad news if need be?
Can I be objective enough not to give too much, too little, or inappropriate care?
Is medical involvement likely to provoke or intensify intrafamilial or intrarelationship conflicts?
Will the patient adhere more readily to medical recommendations delivered by unrelated health personnel?
Will I allow the doctor to whom I refer the patient to assume responsibility for their health care?
Am I willing to be accountable to my peers and to the public for this care?
The Council for Medical Ethics supports the recommendations of other associations with professional codes of practice and strongly advises all doctors who are debating whether to act as a treating physician for family and close friends to consider the above-mentioned issues carefully before deciding.