All professionals are concerned about maintaining the appropriate limits in their relationships with those they serve. Pediatricians should be aware that, under normal circumstances, caring for one's own children presents significant ethical issues. Pediatricians also must strive to maintain appropriate professional boundaries in their relationships with the family members of their patients. Pediatricians should avoid behavior that patients and parents might misunderstand as having sexual or inappropriate social meaning. Romantic and sexual involvement between physicians and patients is unacceptable. The acceptance of gifts or nonmonetary compensation for medical services has the potential to affect the professional relationship adversely.
Physicians and the public recognize the need for high moral standards and accountability in medicine. Most commonly, the focus of concern involves physician competence and integrity, as demonstrated by such measures as board certification, hospital credentialing, peer review of practice, participation in impaired physician programs, and malpractice litigation. Physician behavior is guided by various practice guidelines, review articles, policy statements by professional organizations, and applicable laws and regulations. Codes of ethics for physicians have a role in addressing personal and other nontechnical aspects of physician conduct, as exemplified by the American Medical Association's periodically updated code1 and a 2008 document from the American College of Obstetricians and Gynecologists.2 The American Academy of Pediatrics also has issued policy statements titled “The Use of Chaperones During the Physical Examination of the Pediatric Patient”3 and “Professionalism in Pediatrics: Statement of Principles.”4
This statement delineates the appropriate professional boundaries5 between pediatricians who provide medical care for children (including their own) and their patients and patients’ family members. The American Academy of Pediatrics believes that pediatricians must exercise substantial care in nonprofessional relationships with patients and families to promote the highest possible degree of trust in the doctor-patient-family relationship.
PROVIDING MEDICAL CARE FOR ONE'S OWN CHILDREN
Pediatricians, because of their unique expertise, often find themselves in the position of providing medical advice and treatment for their own children (and minor relatives as well as the children of close friends). Although such activities seem to be common,6–9 the American Medical Association10 considers the practice of treating immediate family members inappropriate. The normal feelings that pediatricians have for their patients can be distorted when the patients are their own children. Pediatricians, when providing medical care for their own children, are more likely to lack objectivity, function with incomplete information, and have difficulty setting physician-patient boundaries. Significant confidentiality issues could arise when caring for minor relatives and the children of close friends. By providing potentially less-than-optimal care for these children, pediatricians violate a fundamental professional obligation. Exceptions to the general prohibition are limited to minor treatments and decisions (often similar to those handled by nonphysician parents) or clear emergencies and disasters and for pediatricians who practice in underserved areas in which there are no other physicians capable of providing pediatric care. If at all possible, the treating pediatrician should notify the child's primary care physician of treatment plans and prescriptions to ensure continuity of care.
GIFTS OR OTHER EXPRESSIONS OF AFFECTION OR GRATITUDE
Patients or parents sometimes give pediatricians gifts, especially after providing help for a complex or troubling health-related problem. Under most circumstances, gifts have a far more symbolic than material value.11 For most pediatricians, accepting modest gifts does not involve a serious conflict; in fact, refusal of a gift may constitute a social or cultural affront. As the monetary worth of the gift increases, however, so does the psychological and ethical difficulty in maintaining appropriate boundaries in the professional relationship. When the pediatrician feels uncomfortable with a gift that a family insists on delivering, he or she must voice the concern and suggest acceptable alternatives, such as a charitable donation in the pediatrician's name. Highly valued gifts may indicate that these boundaries have been crossed. The patient or loved one may have misinterpreted the pediatrician's earlier behavior or may be inviting the pediatrician to engage in a relationship that could compromise medical judgment and action.
ROMANTIC AND SEXUAL RELATIONSHIPS
It is difficult to find reliable data on the prevalence of sexual contact between physicians and their patients or their patients’ family members. Authors of position papers about psychiatrists12 and obstetricians13 have commented on the lack of well-conducted, reliable studies on professional boundary violations by physicians. Attention to the subject, in the form of complaints against practitioners and publications in professional journals, has been more prominent among psychiatrists and obstetricians/gynecologists.14–18 Interpersonal entanglements raise at least 2 serious questions. First, can a patient or family member make clear and free choices to accept or reject affections, especially sexual, in the context of the unavoidably unequal physician-patient-family relationship? Second, once such intimacy develops, can the parties maintain a proper and effective therapeutic relationship?
Because pediatricians provide counseling services for patients and families, these concerns closely parallel those faced by mental health professionals. Pediatricians who feel sexually attracted to their patients may put the patients at risk of sexual abuse or exploitation.19 A more common circumstance, however, is that pediatricians may be misunderstood when they first discuss sexual maturation and sexuality with patients.20 Similarly, examination of an adolescent's maturing genitals or breasts during an office visit may be distressing or misunderstood by the patient, especially if a parent or chaperone is not in the examining room.3 Pediatricians should develop and follow clear and consistent office policies about the presence of a chaperone during parts of the physical examination, taking into account context, local customs, families’ religious and cultural traditions, and the need for patient privacy. Pediatricians should include notations in the record if they do not adhere to the documented office policy requiring the presence of a chaperone.
Pediatricians also interact with the parents or guardians of their patients, although seldom in doctor-patient relationships. Pediatricians are responsible for maintaining appropriate professional boundaries with the families of their patients, although their obligations toward them may be somewhat different from those toward their patients.
There is an inherent risk of exploitation for patients or family members who depend on the knowledge and authority of the pediatrician, especially in cases that involve nonroutine health care. The success of the doctor-patient or doctor-family relationship depends on the ability of the patient or family member to trust the pediatrician completely. Patients and family members legitimately expect to feel physically and emotionally safe in professional relationships with pediatricians. They should not feel vulnerable to romantic or sexual advances while receiving medical care for themselves or their children. In addition, children should be free from concern that their treatment may be compromised by a nonprofessional relationship between a parent and their pediatrician. Children should not have to worry about confidentiality or have anxiety over the potential for the pediatrician to have a conflict of loyalty because of the pediatrician's involvement with the parent.
Patients or family members, to some extent, identify with and feel gratitude toward pediatricians. At times, these feelings may result in efforts to initiate a nonprofessional relationship with the physician or may leave the patient or family member consciously or otherwise unwilling or unable to reject a pediatrician's romantic or sexual advances. Any confusion between complex professional bonds and extraprofessional personal relationships may leave the patient or family member unable to exercise the best judgment or choice about medical matters.
The clinical judgment of pediatricians who become intimately involved with a patient or family member may become clouded, and they may breach their professional responsibilities. Whether this possibility extends to close family members of patients is somewhat less clear. If the intimacy develops in the context of a patient's serious illness, concerns about exploitation of the family member's dependency on the pediatrician arise. Under these circumstances, the pediatrician is well advised to end the professional relationship after ensuring the transfer of the patient's medical care to another appropriate practitioner. Nevertheless, proscriptions on pediatricians pursuing relationships with parents or adult siblings of their patients may, in unusual circumstances, result in unnecessary and inappropriate restrictions on the pediatrician's personal life.
INADVERTENT SEXUALITY IN THE PEDIATRICIAN-PATIENT RELATIONSHIP
Pediatricians usually prefer warm, friendly relationships with their patients. The need to avoid untoward personal intimacy should not lead to a cold, indifferent manner in their interactions with patients or family members. Many cultures expect physical expressions of care and concern in times of personal crisis, including sickness. Pediatricians might well be seen as unsympathetic and excessively remote if they avoid handshakes or other socially approved touching during emotional encounters with families. In most social groups in the United States, interaction with children is likely to involve appropriate physical contact such as hugging.
Pediatricians should be aware of their patients’ customs and personal and religious beliefs. In addition, it may be helpful to recognize that some kinds of touching may be confusing or offensive to children, depending on their stage of physical and emotional maturation. For example, certain children may have strong preferences about whether their physical examination is performed by a male or female pediatrician or whether someone else besides the pediatrician is present during the examination. Anticipatory discussion of these issues should reduce fears and misunderstandings and lead to enhanced pediatrician, patient, and family comfort.
Pediatricians also have an obligation to recognize that physical interaction is not the only means by which humans communicate sexually. Body language and verbal expressions also convey attitudes and emotions that may provoke strong feelings. Because socioeconomic or cultural groups may differ in what they consider acceptable or expected behavior, it is usually best to ask patients and parents their preferences about how they would like to be addressed.17 For example, pediatricians should use neutral language or names in addressing patients rather than using terms of endearment such as “honey” or “dear.” Words that could be seen as evaluative or provocative when referring to body parts, such as the breasts, should be avoided. Personal questions about family history and household functioning should be asked in a way that clearly indicates that their sole purpose is to assist in optimizing the child's development.
Patients or family members may want to compensate pediatricians with an exchange of services or with barter. For example, an adolescent or the adolescent's parents may offer the patient's services as a baby-sitter or gardener in lieu of monetary payment for care. Such arrangements vary legitimately with local custom and the economic circumstances of patients and families. However, problems may arise about exactly what services constitute adequate compensation for professional care and the appropriateness of increased personal contact between the patient or family member and the pediatrician. Nonmonetary payments, as with gifts, may become precursors to boundary violations and should be approached with caution.
Pediatricians should know that caring for one's own children and caring for the minor children of relatives and close friends, particularly outside of the doctor-patient relationship, presents significant ethical issues, including issues of confidentiality, and may lead to less-than-optimal medical care. Exceptions exist for treatment of minor conditions or during emergencies and disasters and in underserved areas in which alternatives are unavailable.
It may be acceptable for pediatricians to accept modest gifts from patients and their families. When the pediatrician feels uncomfortable with a gift that a family insists on delivering, he or she should suggest acceptable alternatives such as a charitable donation in the pediatrician's name. However, caution is urged when the material value of gifts or offered services could seem to influence the pediatrician's professional judgment. Furthermore, the pediatrician must be sensitive to the possibility that the intent of the gift is, in fact, to alter behavior.
Pediatricians caring for children and adolescents need to be aware of the potential for conflict between their professional roles and their personal relations with their patients and their patients’ family members. Romantic and/or sexual relationships with patients are always inappropriate. Romantic or sexual relationships with adult family members of patients should be avoided, given the potential for adverse effects on professional judgment and family-member behavior concerning the patient's health.
In providing care for children and adolescents, pediatricians need to be aware that their words, body language, and other aspects of professional conduct may inadvertently offend or insult patients and family members depending on both the context of the event and local customs. Many expressions and actions during the physical examination may have an unintended sexual connotation for the patient or parent. Pediatricians are advised to use neutral language that is acceptable to the patient and to discuss thoroughly and in advance aspects of care that may seem sexually charged. Personal questions about family history and household functioning need to be asked in the context of optimizing the child's development.
Medical school, residency, and continuing medical education programs should routinely discuss the importance of personal boundaries between professionals, their patients, and their patients’ family members.
COMMITTEE ON BIOETHICS, 2008–2009
Douglas S. Diekema, MD, MPH, Chairperson
Mary Fallat, MD, Chairperson-Appoint
Armand H. Matheny Antommaria, MD, PhD
*Ian R. Holzman, MD
Aviva L. Katz, MD
Steven R. Leuthner, MD, MA
Lainie F. Ross, MD, PhD
Sally A. Webb, MD
Philip L. Baese, MD
American Academy of Child and Adolescent Psychiatry
Marcia Levetown, MD
American Board of Pediatrics
Anne D. Lyerly, MD
American College of Obstetricians and Gynecologists
Ellen Tsai, MD, MHSc
Canadian Paediatric Society
Jessica Wilen Berg, MPH, JD
Alison Baker, MS
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.