The physician and the patient
The patient-physician relationship entails special obligations for the physician to serve the patient's interest because of the specialized knowledge that physicians hold and the imbalance of power between physicians and patients.
The physician's primary commitment must always be to the patient's welfare and best interests, whether the physician is preventing or treating illness or helping patients to cope with illness, disability, and death. The physician must support the dignity of all persons and respect their uniqueness. The interests of the patient should always be promoted regardless of financial arrangements; the health care setting; and patient characteristics, such as decision-making capacity or social status.
At the beginning of a patient-physician relationship, the physician must understand the patient's complaints, underlying feelings, goals, and expectations. After patient and physician agree on the problem and the goal of therapy, the physician presents one or more courses of action. If both parties agree, the patient may authorize the physician to initiate a course of action; the physician can then accept that responsibility. The relationship has mutual obligations: The physician must be professionally competent, act responsibly, and treat the patient with compassion and respect, and the patient should understand and consent to the treatment that is rendered and should participate responsibly in the care. Although the physician should be fairly compensated for services rendered, a sense of duty to the patient should take precedence over concern about compensation when a patient's well-being is at stake.
Initiating and discontinuing the patient-physician relationship
By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons. Although this obligation is collective, each individual physician is obliged to do his or her fair share to ensure that all ill persons receive appropriate treatment. A physician may not discriminate against a class or category of patients (17).
An individual patient-physician relationship is formed on the basis of mutual agreement on medical care for the patient. In the absence of a preexisting relationship, the physician is not ethically obliged to provide care to an individual person unless no other physician is available, as is the case in some isolated communities or when emergency treatment is required. Under these circumstances, the physician is morally bound to provide care and, if necessary, to arrange for proper follow-up. Physicians may also be bound by contract to provide care to beneficiaries of participating health plans.
Physicians and patients may have different concepts of the meaning and resolution of medical problems. The care of the patient and satisfaction of both parties are best served if physician and patient discuss their expectations and concerns. Although the physician must address the patient's concerns, he or she is not required to violate fundamental personal values, standards of scientific or ethical practice, or the law. When the patient's beliefs—religious, cultural, or otherwise—run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient. If the physician is unable to carry out the patient's wishes after seriously attempting to resolve differences, the physician should transfer the care of the patient.
Under exceptional circumstances, the physician may discontinue the professional relationship by notifying the patient and, with the approval of the patient, transfer to another physician the information in the record, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process. Continuity of care must be assured to the best of the physician's ability. Physician-initiated termination is a serious event, especially if the patient is acutely ill, and should be undertaken only after genuine attempts are made to understand and resolve differences. A patient is free to change physicians and is entitled to the information contained in the medical records.
Confidentiality
Confidentiality is a fundamental tenet of medical care. It is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions. The physician must not release information without the patient's consent (often termed a "privileged communication"). However, confidentiality, like other ethical duties, is not absolute. It may have to be overridden to protect individual persons or the public—for example, to warn sexual partners that a patient has syphilis or is infected with HIV—or to disclose information when the law requires it. Before breaching confidentiality, the physician should make every effort to discuss the issues with the patient. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable federal and state law.
Confidentiality is increasingly difficult to maintain in this era of computerized record keeping and electronic data processing, faxing of patient information, third-party payment for medical services, and sharing of patient care among numerous medical professionals and institutions. Physicians should be aware of the increased risk for invasion of patients' privacy and should help ensure confidentiality. Within their own institutions, physicians should advocate policies and procedures to secure the confidentiality of patient records.
Discussion of the problems of an identified patient by professional staff in public places (for example, in elevators or in cafeterias) violates confidentiality and is unethical. Outside of an educational setting, discussions of a potentially identifiable patient in front of persons who are not involved in that patient's care are unwise and impair the public's confidence in the medical profession. Physicians of patients who are well known to the public should remember that they are not free to discuss or disclose information about a patient's health without the explicit consent of the patient.
In the care of the adolescent patient, family support is important. However, this support must be balanced with confidentiality and respect for the adolescent's autonomy in health care decisions and in relationships with health care providers (18). Physicians should be knowledgeable about state laws governing the right of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment.
Occasionally, the physician receives information from a patient's friends or relatives and is asked to withhold the source of that information from the patient (19). The physician is not obliged to keep such secrets from the patient. The informant should be urged to address the patient directly and to encourage the patient to discuss the information with the physician. The physician should use sensitivity and judgment in deciding whether to use the information and whether to reveal its source to the patient. The physician should always act in the best interests of the patient.
The patient and the medical record
Ethically and legally, patients have the right to know what is in their medical records. Legally, the actual chart is the property of the physician or institution, although the information in the chart is the property of the patient. Most states have laws that guarantee the patient personal access to the medical record. The physician must release information to the patient or to a third party at the request of the patient. Physicians should retain the original of the chart and radiographic studies and respond to a patient's request with copies unless the original record is required by law. To protect confidentiality, information should only be released with the written permission of the patient or the patient's legally authorized representative.
Disclosure
In order to make health care decisions and work intelligently in partnership with the physician, the patient must be well informed. Effective patient-physician communication can dispel uncertainty and fear and can enhance healing and patient satisfaction. Information should be disclosed whenever it is considered material to the patient's understanding of his or her situation, possible treatments, and probable outcomes. This information often includes the costs and burdens of treatment, the experience of the proposed clinician, the nature of the illness, and potential treatments.
However uncomfortable to clinician or patient, information that is essential to the patient must be disclosed. How, when, and to whom information is disclosed are important concerns that must be addressed.
Information should be given in terms that the patient can understand. The physician should be sensitive to the patient's responses in setting the pace of disclosure, particularly if the illness is very serious. Disclosure should never be a mechanical or perfunctory process. Upsetting news and information should be presented to the patient in a way that minimizes distress (20, 21). If the patient is unable to comprehend his or her condition, it should be fully disclosed to an appropriate surrogate.
In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.
Any unauthorized touching of a person is battery, even in the medical setting. The patient's consent allows the physician to provide care.
Consent may be either expressed or implied. Expressed consent most often occurs in the hospital setting, where written or oral consent is given for a particular procedure. In many medical encounters, when the patient presents to a physician for evaluation and care, consent can be presumed. The underlying condition and treatment options are explained to the patient, and treatment is rendered or refused. In medical emergencies, consent to treatment that is necessary to maintain life or restore health is usually implied unless it is known that the patient would refuse the intervention.
The doctrine of informed consent goes beyond the question of whether consent was given for a treatment or intervention. Rather, it focuses on the content and process of consent. The physician is required to provide enough information to allow a patient to make an informed judgment about how to proceed. The physician's presentation should be understandable to the patient, should be unbiased, and should include the physician's recommendation. The patient's or surrogate's concurrence must be free and uncoerced.
The principle and practice of informed consent rely on patients to ask questions when they are uncertain about the information they receive; to think carefully about their choices; and to be forthright with their physicians about their values, concerns, and reservations about a particular recommendation. Once patients and physicians decide on a course of action, patients should make every reasonable effort to carry out the aspects of care that are in their control or to inform their physicians promptly if it is not possible to do so.
The physician is obligated to ensure that the patient or the surrogate is adequately informed about the nature of the patient's medical condition and the objectives of, alternatives to, possible outcomes of, and risks involved with a proposed treatment.
All adult patients are considered competent to make decisions about medical care unless a court declares them incompetent. In clinical practice, however, physicians and family members usually make decisions without a formal competency hearing in the courts for patients who lack decision-making capacity. This clinical approach can be ethically justified if the physician has carefully determined that the patient is incapable of understanding the nature of the proposed treatment; the alternatives to it; and the risks, benefits, and consequences of it.
When a patient lacks decision-making capacity (that is, the ability to receive and express information and to make a choice consonant with that information and one's values), an appropriate surrogate should make decisions with the physician. Ideally, surrogate decision makers should know the patient's preferences and act in the best interests of the patient. If the patient has designated a proxy, as through a durable power of attorney for health care, that choice should be respected. When patients have not selected surrogates, standard clinical practice is that family members serve as surrogates. Some states designate the order in which family members will serve as surrogates. Physicians should be aware of legal requirements in their state for surrogate appointment and decision making. In some cases, all parties may agree that a close friend is a more appropriate surrogate than a relative.
Physicians should take reasonable care to ensure that the surrogate's decisions are consistent with the patient's preferences and best interests. When possible, these decisions should be reached in the medical setting by physicians, surrogates, and other caregivers. Physicians should emphasize to surrogates that decisions should be based on what the patient would want, not what surrogates would choose for themselves. If disagreements cannot be resolved, hospital ethics committees may be helpful. Courts should be used when doing so serves the patient, such as to establish guardianship for an unbefriended, incompetent patient; to resolve a problem when other processes fail; or to comply with state law.
Most adult patients can participate in, and thereby share responsibility for, their health care. Physicians cannot properly diagnose and treat conditions without full disclosure of patients' personal and family medical history, habits, ongoing treatments (medical and otherwise), and symptoms. The physician's obligation to confidentiality exists in part to ensure that patients can be candid without fear of loss of privacy. Physicians must try to create an environment in which honesty can thrive and patient concerns and questions are elicited.
Decisions about reproduction
The ethical duty to disclose relevant information about human reproduction to the patient may conflict with the physician's personal moral standards on abortion, sterilization, or contraception. A physician who objects to these services need not become involved, whether by offering advice to the patient or by involvement in a procedure. As in any other medical situation, the physician has a duty to refer the patient to an appropriate source for the full range of options so that the patient's legal options are not constrained.
If a patient who is a minor requests termination of pregnancy, advice on contraception, or treatment of sexually transmitted diseases without a parent's knowledge, the physician may wish to attempt to persuade the patient of the benefits of having parents involved but should be aware that a conflict may exist between the legal duty to maintain confidentiality and the obligation toward parents or guardians. Information should not be provided to others without the patient's permission (22). In such cases, the physician should be guided by his or her conscience in light of the law.
Presymptomatic and diagnostic testing raises issues of education, counseling, confidentiality, and justice. Such testing may allow clinicians to predict diseases or clarify susceptibility at a time when medicine may not have the ability to prevent or cure the conditions that are identified. Both the public and health care professionals often have a limited grasp of the distinction between prediction and susceptibility or risk. Genetic testing presents unique problems by identifying risk for disease that has special meaning for patients and for family members who may not be under the care of the clinician providing the test.
Clinicians should discuss with patients the degree to which a particular genetic risk factor correlates with the likelihood of developing disease. Testing should not be undertaken until these issues are fully explored with the patient and the potential consequences of the test, from its impact on the patient's well-being to implications for other family members and use by insurers or other societal institutions, are fully understood.
Because the number of trained genetic counselors is small and is unlikely to match the exponential growth in genetic testing, the generalist clinician is increasingly responsible for conveying genetic test results. Only physicians who are familiar with the skills necessary for pretest and post-test education and counseling should engage in genetic testing (23). All primary care physicians should develop these skills.
As more information becomes available on the genetic risk for certain diseases, physicians must be aware of the need for confidentiality concerning results of genetic tests. Many state governments and the federal government are promulgating rules and regulations that cover access of employers and insurers to such information. Additional complex ethical problems exist, such as which family member should be informed of the results of genetic tests. Physicians should be sensitive to these ethical problems, and testing should not be undertaken until issues are fully discussed and their consequences are well understood.
The potential for stigmatization and insurance and job discrimination require that physicians ensure the confidentiality of data. However, the presence of a genetic risk factor or genetic disease in a family member raises the possibility that other blood relatives are at risk. The physician should seek the affected patient's consent in encouraging potentially affected family members to seek genetic counseling if it may affect treatment or major life decisions.
Medical risk to physician and patient
Traditionally, the ethical imperative for physicians to provide care has overridden the risk to the treating physician, even during epidemics. In recent decades, with better control of such risks, physicians have practiced medicine in the absence of risk as a prominent concern. However, potential occupational exposures such as HIV, multidrug-resistant tuberculosis, and viral hepatitis necessitate reaffirmation of the ethical imperative (24).
Physicians should evaluate their risk for becoming infected with pathogens, both in their personal lives and in the workplace, and implement appropriate precautions. Physicians who may have been exposed to pathogens have an ethical obligation to be tested and should do so voluntarily. Infected physicians should place themselves under the guidance of their personal physician or the review of local experts to determine in a confidential manner whether practice restrictions are appropriate on the basis of the physician's compliance with infection control precautions and physical and mental fitness to work. Infection does not in itself justify restrictions on the practice of an otherwise competent health care worker. Health care workers are expected to comply with public health and institutional policies.
Because the diseases mentioned above may be transmitted from patient to physician and because they pose significant risks to physicians' health and are difficult to treat or cure, some physicians may be tempted to avoid the care of infected patients. Physicians and health care organizations are obligated to provide competent and humane care to all patients, regardless of their disease state. Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous application of infection control methods. The denial of appropriate care to a class of patients for any reason is unethical (25).
Whether physicians should disclose their condition depends on the likelihood of risk to the patient and relevant law or regulations in their locales. Physicians should remove themselves from care if it becomes clear that the risk associated with contact or with a procedure is significant even if appropriate preventive measures are taken. Physicians are also obligated to disclose their condition after the fact if a clinically significant exposure has taken place.
Physicians have several obligations concerning nosocomial risk of infection. They should help the public to understand the low level of this risk and put it in the perspective of other medical risks while acknowledging public concern. Physicians provide medical care to health care workers, and part of this care is discussing with health care workers their ethical obligation to know their risk for such diseases as HIV or viral hepatitis, to voluntarily seek testing if they are at risk, and to take reasonable steps to protect patients. The physician who provides care for a seropositive health care worker must determine the health care worker's fitness to work. In some cases, seropositive health care workers cannot be persuaded to comply with accepted infection control guidelines, or impaired physicians cannot be persuaded to restrict their practice. In such exceptional cases, the treating physician may need to breach confidentiality and report the incident to the appropriate authorities in order to protect patients and maintain public trust in the profession, even though such actions may have legal consequences.
Alternative treatments
Alternative or complementary medicine is a common term for health practices that generally are not available from U.S. physicians, are not offered in U.S. hospitals, and are not widely taught in U.S. medical schools (26). The physician should not abandon the patient who elects to try an alternative treatment. Requests by patients for alternative treatment require balancing the medical standard of care with a patient's right to choose care on the basis of his or her values and preferences. Such a request warrants careful attention from the physician. Before advising a patient, the physician should ascertain the reason for the request: for example, whether it stems from dissatisfaction with current care (27). The physician should be sure that the patient understands his or her condition, standard medical treatment options, and expected outcomes.
The physician should encourage the patient requesting alternative treatment to seek literature and information from reliable sources. The patient should be clearly informed if the option under consideration is likely to delay access to effective treatment or is known to be harmful. The physician need not participate in the monitoring or delivery of alternative care to the patient. However, physicians should recognize that some patients may select alternative forms of treatment; this decision alone should not be cause to sever the patient-physician relationship.
Some patients have chronic, overwhelming, or catastrophic illnesses. In these cases, society permits physicians to justify exemption from work and to legitimize other forms of financial support.
In keeping with the role of patient advocate, a physician should assist a patient who is medically disabled in obtaining the appropriate disability status (28). Disability evaluation forms should be completed factually, honestly, and promptly.
Physicians will often find themselves confronted with a patient whose problems may not fit standard definitions of disability but who nevertheless seems deserving of assistance (for example, the patient may have very limited resources or poor housing). Physicians should not distort medical information or misrepresent the patient's functional status in a misguided attempt to help these patients. The trustworthiness of the physician is jeopardized, as is his or her ability to advocate for patients who truly meet disability or exemption criteria.
Care of the physician's family, friends, and employees
Physicians should avoid treating themselves, close friends, or members of their own families. Physicians should also be very cautious about assuming the care of closely associated employees. Problems may include inadequate history taking or physical examination as a result of role-related discomfort on the part of patient or physician. The physician's emotional proximity can result in a loss of objectivity. If a physician does treat a close friend, family member, or employee out of necessity, the patient should be transferred to another physician as soon as it is practical. Otherwise, requests for care on the part of employees, family members, or friends should be resolved by assisting them in obtaining appropriate care. Fulfilling the role of informed and loving adviser, however, is not precluded.
Sexual contact between physician and patient
Issues of dependency, trust, and transference and inequalities of power lead to increased vulnerability on the part of the patient and require that a physician not engage in a sexual relationship with a patient. It is unethical for a physician to become sexually involved with a current patient even if the patient initiates or consents to the contact.
Even sexual involvement between physicians and former patients raises concern. The impact of the patient-physician relationship may be viewed very differently by physicians and former patients, and either party may underestimate the influence of the past professional relationship. Many former patients continue to feel dependency and transference toward their physicians long after the professional relationship has ended. The intense trust often established between physician and patient may amplify the patient's vulnerability in a subsequent sexual relationship. A sexual relationship with a former patient is unethical if the physician "uses or exploits the trust, knowledge, emotions or influence derived from the previous professional relationship" (29). Because it may be difficult for the physician to judge this influence, we advise consultation with a colleague or other professional before becoming sexually involved with a former patient (30).
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