A primary care physician sees a woman whose regular doctor is out of town. She comes in for a refill of zolpidem tartrate, which she is taking for insomnia. She is otherwise completely healthy, and after confirming that her primary doctor has prescribed it, the physician refills her medication for a few days until the other physician returns. The physician engages the patient in a brief discussion of the life stresses contributing to her insomnia, but no physical exam is performed.
Several weeks later the physician meets the patient at a social gathering and she invites him to dinner. He initially refuses, saying he can't because he has seen her as a doctor. She convinces him that no ongoing physician-patient relationship exists, and a romantic relationship ensues. Several months later they break up, and the next week she files a complaint with the medical center alleging that the physician exploited her vulnerability. She says she must transfer her care to another institution because the possibility of seeing this physician, or one of his colleagues she met while involved, is so unsettling.
A sexual relationship with a current patient is unequivocally forbidden in all codes of medical ethics, going back to the Hippocratic Oath: “In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men.”
However, is it a serious breach of ethical standards if, as in this case, there is no ongoing physician-patient relationship? According to ACP's Ethics Manual, 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.”
While these standards articulated by the College, as well as the American Medical Association and others focus (properly) on possible exploitation of the individual patient, there are also clinical and moral dangers for physicians if our profession does not insist on rejecting the possibility that a clinical interaction might lead to romance.
Patients cannot feel completely secure with a doctor if they believe there is even a small chance the physician is contemplating romantic involvement. Thus, physicians must remain closed to the possibility of such involvement with patients in order to approach all encounters in an entirely professional manner.
If a patient and a physician disagree about whether an intimate relationship involved exploitation of an earlier professional interaction, then with few (but not zero) exceptions, the patient's judgment should and will prevail. If I were part of a disciplinary committee reviewing this case, I would have to conclude there was a violation of professional standards. To do otherwise would show insufficient seriousness in upholding strict professional limits. I would do this with some discomfort, because it would likely mean that on future applications for licensure or credentials the physician would have to report that he had been the subject of disciplinary action and explain the details.
It is impossible to define exact boundaries between acceptable and unacceptable behavior in this area. I might, for example, reach a different conclusion if the clinical interaction involved a minute or two to remove a splinter from a finger, rather than a discussion of the patient's emotional stresses.
As a practical matter, physicians should assume that any prior physician-patient relationship is incompatible with a subsequent sexual relationship. But we can all imagine exceptions where the relationship was trivial and/or distant in time. For these, the best we can do is to follow the advice of the College's Ethics Manual: “Because it may be difficult for the physician to judge the impact of the previous professional relationship, the physician should consult with a colleague or other professional before becoming sexually involved with a former patient.”
In reviewing the case, the medical center's disciplinary committee determined that the physician, while highly regarded by all of his colleagues and never the subject of any prior complaint, had violated ethical standards of professionalism. He was placed on probation for one year and required to undertake study of codes of professionalism.