Managing Boundaries

Moral authority and the social contract

The medical profession's moral authority is in the first instance formally conferred by society through the process of licensing or registration. This is the social contract through which doctors are accorded special status in return for a particularly stringent set of behavioural expectations. Doctors will use the best of their ability, knowledge, skills and judgement in the service of the patient. The social contract establishes an a priori assumption of trustworthiness of the profession which enables patients to reveal intimacies of mind and body. The reality of that assumption is tested in each encounter between a patient and practitioner.

In an operational sense the social contract also establishes the rules of engagement for the consultation. Doctors are obliged to: be competent, behave ethically and professionally, have good interpersonal and communication skills, demonstrate common decency, and offer compassionate and empathic care. Patients will also deal fairly by respecting doctors' positive and negative rights, and adopting the normal expectations of the sick role: patients should know that they are ill, want to get well, seek help appropriately, and follow reasonable advice.

The doctor-patient relationship

The doctor-patient relationship is unique among professional relationships precisely because of the nature and degree of intimacies shared. The patient's anxiety, need, dependence, and loss of control and autonomy equate to a substantial power imbalance in the doctor-patient relationship. There is potential for exploitation of the patient by the doctor. This imbalance of power imposes a great responsibility on the doctor to behave according to the highest ethical standards. Any breach of this responsibility will diminish the moral authority of the individual doctor and of the profession as a whole. Furthermore, tribunals tend to reject the idea that patient consent for, or collusion in, boundary transgression should have any bearing on judgements of the appropriateness or reasonableness of a doctor's actions.

Boundaries in the doctor-patient relationship

Another characteristic of this special relationship is that the doctor commits to use the encounter solely in the service of the patient. The doctor in return receives only remuneration and the personal satisfaction of doing meaningful work. Specifically the doctor will not exploit the professional relationship for any other personal or self-serving purpose. This, for example, might include:

• improper influence, persuasion or manipulation
• improper gain, whether financial or informational
• receiving favours or gifts, including sexual favours
• selling something, literally (drugs, or investment schemes) or metaphorically (religion, politics)
• role reversal, in which the doctor improperly seeks care, succour or 'therapy'.

In short, whatever transpires between the doctor and the patient in this professional relationship should address the patient's concerns and should not be about the doctor. Unlike a social relationship, it is a one-way arrangement; everything that goes on in the medical consultation is in the service of the patient and the doctor must never impose his or her needs on the patient.

An important example is that doctors should be particularly aware that self-revelation is fraught. Judicious self-revelation may occasionally be acceptable if it is genuinely in the service of the patient. It is often benignly misunderstood by doctors as good empathic sharing – the "I've been there" idea – when it is in fact often gratuitous, and indeed sometimes a product of blatant neediness on the part of the doctor.

Boundary transgression

Boundary transgressions can be divided into boundary crossings and boundary violations.

• Boundary crossings are departures from usual practice that are not exploitative and can sometimes be helpful to the patient.
• Boundary violations are transgressions which are harmful to patients.

An example of a benign boundary crossing might be giving a young mother a lift home at the end of the day when it is raining, it is late and it is on your way home. But what if you have always found the person to whom you are giving a lift especially attractive? This may already be a boundary violation. Ask yourself why you are really doing this. And what if it starts to become routine, because you have decided to see this patient regularly in the last appointment of the day? And what if you decide after a while to stop and have a coffee or a drink on the way home? Are you telling your partner about this? Because this is not just a boundary violation; it could be about to ruin your life and the lives of many others around you.

TABLE 1. Identifying risky boundary behaviour – the checklist

Always be prepared to check your behaviour against this list.

• Is what I'm doing part of accepted medical practice?
• Does what I'm doing fit into any of the recognised high-risk situations that I have learnt about?
• Is what I'm doing solely in the interest of the patient?
• Is what I'm doing self-serving?
• Is what I'm doing exploiting the patient for my benefit? Is what I'm doing gratuitous (not what the patient has asked for)? Is what I'm doing secretive or covert? Would I be happy to share it with my spouse, partners or colleagues?
• Am I revealing too much about myself or my family?
• Is what I'm doing causing me stress, worry or guilt?
• Has someone already commented on my behaviour, or suggested I stop?

TABLE 2. Additional Self-Test questions for Dual Relationships – treating family, friends or colleagues

• Am I doing this to raise my own status or in some other way gratify myself?
• Am I too close to be objective in my management of "Tom"?
• Can I perform intimate examinations of "Mary" or ask her intimate or sensitive questions?
• Can our personal relationship survive a professional error or disagreement?

Factors that increase the risk of boundary violation

We know that certain factors increase the risk of boundary violation. Doctors who are under stress, particularly relationship stress, are at increased risk of boundary violation. Those who are in solo practice, who are professionally isolated and/or emotionally unsupported, are also at greater risk. Finally, certain psychiatric states tend to increase the risk. These include dependent and narcissistic personality disorders, depression, and alcohol and substance abuse.

Patients who are more likely to violate boundaries include those with vulnerabilities of various types such as borderline and dependent personality disorders. Notably, female patients who have been sexually abused in the past are especially at risk of being abused again in professional relationships. Borderline patients in particular may initiate inappropriate relationships and may test boundaries with active flirtation. Other demanding patients may push doctors in ways that violate professional and ethical norms, some of which may result in the doctor violating professional boundaries.

Dual relationships

The term "dual relationships" describes situations where a professional relationship is used to establish a parallel personal relationship.

Classic examples of dual relationships are treatment of intimates including close friends, staff and associates. These situations are fraught because of the loss of objectivity. They have the potential to permanently damage personal relationships and consequent entanglements can have legal and administrative ramifications. When treating one's own family the price is potentially higher.

Treating oneself has always been recognised as stupid, but at least the main victim is you! As Osler is quoted as saying in Aphorisms, "A physician who treats himself has a fool for a patient".
The ultimate improper "dual relationship" is the sexual relationship with a patient. This topic has been well rehearsed elsewhere but it needs to be said unequivocally that it is forbidden. Such conduct ruins lives and further degrades the perception of the profession.

Professor Geoff Riley AM is the Winthrop Professor of Rural and Remote Medicine and Head of the Rural Clinical School of WA.