Q: What is the appropriate response for an internist to the phone call from a friend….”I hate to ask you but,….I have this minor problem and could you help me over the phone or in your/my house?” Some of these friends are officially your patient, some are not. I have dealt with this twice already this week.
–Deborah Shapiro MD
A: Commentary by Antonella Surbone MD PhD FACP, NYU Department of Medicine, Ethics Section Editor
The issue of dealing with taking care of family and friends is one that we all may face often, if not daily, and it may helpful to delineate the ethical implications of refusing to help or helping too much. Medical care, even when limited to providing advice, carries consequences and responsibilities. Family and friends tend to ask, but then not to necessarily to follow, our recommendations, as they occur outside a structured therapeutic relationship.
The patient-doctor is an asymmetrical relation of help, born from the patient’s need of the knowledge and expertise of the physician and based on reciprocal responsibilities and obligations in view of a shared therapeutic goal. The patient-doctor relationship requires proper boundaries and honesty regarding each party’s roles and expectations, in order to assure that reciprocity goes along with the necessary distance and authority. Physicians earn this through their professional competence and adherence to high ethical standards.
Most medical codes of ethics discourage taking care of relatives and close friends, because of potentially excessive emotional involvement of the physician that may cloud his or her clinical judgment. In many countries, physicians are also warned against possible legal repercussions.
We all, however, find ourselves in situations similar to the ones described by Dr. Deborah Shapiro, or even in worst scenarios, when the relative or close friend ask for opinions or advices about serious illness, such as cancer. Dr. Shapiro describes friends (at times also her patients) who request medical advice for what they consider a relatively minor problem, and ask to be seen at home. In my personal experience as a medical oncologist working on both sides of the ocean, requests of family and friends for my opinion about the quality of individual oncologists or cancer institutions are very frequent, as are requests for informal second opinions about cancer treatment.
These requests can be burdensome, as friends or relatives almost always pose their questions in terms of urgency and expect our immediate availability. This often generates frustration, especially since, in most cases, friends or family members do not end following our advice and often fail follow-up with us on their condition and treatment. At times, a friend calls after months or even years expecting us to remember all details of an opinion that we gave by phone or over a cup of coffee.
Yet, what should we do? The key to being a good physician is caring for the well being of other persons, and we cannot exclude friends and family from those we care about. The effectiveness of help that we can give our patients, and also our friends and relatives, however, is greatest when the obligations and limitations of the patient-doctor relationship are explicated and respected.
Cross-cultural variables may also influence our decision to provide advice or care to family and friends. Physicians who know most of their neighbours are more available to provide advice or make informal house calls, as they know more about the lives of their friends and neighbours than is the case for most physicians in industrialized countries or urban areas.
The ethical issues involved are complex and go beyond the space limitations of my answer to Dr. Shapiro. Responding to the requests for medical advice and occasionally care of our friends or relatives is an act of altruism that can be highly rewarding. Yet, it is ethically wrong to becoming excessively involved when the friend is not our patient and is under the care of another physician, or to provide too detailed advice without knowing all the facts and history, or to answer medical questions that go beyond our field of expertise.
The patient-doctor relationship is an asymmetrical professional relation with clear boundaries and responsibilities. The ethics of this relation requires that we discern when the demands of friends and relatives are reasonable or inappropriate and act based on our own comfort level with respect to the physician in us. Without being afraid to ruin a friendship or a family bond, on occasions we can tactfully say “I’m not comfortable discussing this subject with you and I’d prefer to let your doctor give you advice, since he or she knows your case and is treating you.” In many other occasions, we can provide simple and clear answers, offer our help as navigators, or assist our friends and relatives at times of difficult decision-making.
Surbone A, Lowenstein J. Asymmetry in the patient-doctor relationship. J Clin Ethics 2003:14: 183-188.