BMJ  2006;333:1132 (2 December), doi:10.1136/bmj.39042.529641.BE

Editorials

Sexual relationships between doctors and former patients

New guidance gets the balance right in stopping short of a complete ban

In new guidance, the General Medical Council (GMC) has warned doctors to think long and hard before embarking on a sexual relationship with a former patient. It has not introduced a blanket ban, which might have been vulnerable to a human rights challenge, but it is far from permissive. The guidance says such a relationship "may be inappropriate irrespective of the length of time elapsed."¹ The guidance will not please everyone.

Consider the general practitioner in a remote rural practice. The edict could cast the shadow of inappropriate behaviour across any future partner he or she may meet. Surely the medical oath did not include a vow of chastity? Previously the GMC prohibited only relationships with current patients. So what of those relationships already under way? Are these now subject to suspicion? Should doctors in such relationships, as the guidance infers, discuss their relationships with a member of the GMC standards and ethics team?

Clearly the focus is on vulnerable patients. Behind the guidance can be felt the pressure of the inquiries into Clifford Ayling, William Kerr, and Michael Haslam. In these cases, predatory doctors sexually exploited vulnerable patients entrusted to their care.^{2 3} A balancing act is needed then, which acknowledges the freedoms of competent adults to form relationships but also protects the interests of vulnerable patients. Has the GMC got the balance right?

Traditionally the doctor-patient relationship has been seen as characterised by an imbalance of power, with the doctor in the position of authority. "A relationship between a doctor and a patient is never really equal" argues the GMC's president, Graeme Catto.⁴ By prohibiting behaviour that is not in the best interests of patients, codes of ethics have enabled doctors to concentrate on doing the best for their patients. In this way, the power of the doctor is harnessed to the good, engendering trust and maximising therapeutic outcomes. Professionalism demands that both parties are protected by clear and mutually recognised boundaries. The ethics department of the British Medical Association has advised doctors on how to manage intrusive patients—how to deal with stalkers and those who shower doctors with declarations of undying love.

But isn't such a take on the doctor-patient relationship out of date, even paternalistic? Online resources have reduced the information gap between doctors and patients, patient autonomy is greater than ever before, and not everyone who walks through a consulting room door is a shrinking violet. Some doctors feel that the shoe is now firmly on the other foot. The classic paradigm, with the single handed (usually male) practitioner exploiting vulnerable female patients is less likely today because doctors work in multidisciplinary teams, where such behaviour would be exposed.

It is also easy to think of examples that verge on the absurd; should junior doctors treating fellow medics in accident and emergency be forever precluded from dating them? As the GMC now explicitly prohibits relationships with former patients who were "vulnerable" at the time—itself an interpretative nightmare—is anything additional required? As the patient as consumer comes of age, and the power and status of professionals wanes, is Graeme Catto right or is the doctor-patient relationship now a meeting of equals?

As with so many questions that arise in ethics, the honest answer must be, it depends. Recent history is sadly strewn with sobering examples of doctors abusing their power—Rodney Ledward, Harold Shipman, Peter Green. If so many doctors had not abused their power in the past, calls for restraint would not be as loud. Irrespective of the pressure that the softening of traditional hierarchies of authority is bringing to bear, the doctor-patient relationship remains a kind of exemplar. Patients are often vulnerable when they visit doctors. They can be sick, distressed, and disorientated, even if they express their need in an aggressive or overconfident way.

Patients may need to reveal the most private information. Without the expectation that boundaries will be observed and trust respected, they may be less forthcoming, and patient care will suffer. Information trawled from the internet will never be a substitute for informed professional judgment. It is for the interpretation of such information as much as for its provision that we rely on professionals. So it is a special kind of relationship, rooted in trust as much as contract, governed by professional boundaries that protect doctors as well as patients, and subject in complex ways to the ebb and flow of power.

The GMC has a difficult job to do. In falling short of a blanket ban, in recognising that there will always be exceptions, it has made a wise choice. In case you think this is a recent problem, consider the words of Hippocrates from the fourth century BC, "Into whatever house I enter, I will go into them for the benefit of the sick and will abstain from mischief and corruption and from the seduction of females or males, of freemen or slaves."

¹ Medical Ethics Department, British Medical Association, BMA House, London WC1 9JR

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Competing interests: None declared.

References

1. General Medical Council. Maintaining boundaries. London: GMC, 2006. www.gmc-uk.org/guidance/current/library/maintaining_boundaries.asp.
2. Department of Health Committee of Inquiry. Independent investigation into how the NHS handled allegation about the conduct of Clifford Ayling. London: DOH, 2004. www.dh.gov.uk/assetRoot/04/08/90/65/04089065.pdf.
3. HM Government. The Kerr/Haslam inquiry. Norwich: Stationery Office, 2005. www.official-documents.co.uk/document/cm66/6640/6640.pdf.
4. Eaton L. Doctors are warned against sex with former patients. BMJ 2006;333:876.[Free Full Text]

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