Treating Self and Family Members

Professional Standards and Guidelines Regarding Treating Self and Family Members

Preamble

Whenever a physician treats someone with whom he or she has a personal relationship, there is a risk that the relationship will affect the physician’s ability to provide good-quality, clinically objective care.  Similar issues exist when physicians engage in self-treatment.

Providing appropriate medical care within the context of a personal relationship is problematic because of the difficulty in defining and maintaining appropriate boundaries.

For the purposes of this document the following definitions apply:

• “Family member” means a physician’s spouse or partner, parent, child, sibling, grandparent or grandchild; a parent, child, sibling, grandparent or grandchild of the physician’s spouse or partner; or another individual in relation to whom the physician has personal or emotional involvement that may render the physician unable to exercise objective professional judgment in reaching diagnostic or therapeutic decisions.
• “Treating” includes ordering and performing tests, making and communicating a diagnosis and prescribing medications. It does not include the monitoring of a condition that may be done by a non-physician.
• “Minor condition” is generally a non-urgent, non-serious condition that requires only short-term, routine care and is not likely to be an indication of, or lead to, a more serious condition.
• An “emergency” exists where an individual is apparently experiencing severe suffering or is at risk of sustaining serious bodily harm if medical intervention is not promptly provided.

This standard reflects ethical responsibilities of physicians set out in the Canadian Medical Association’s Code of Ethics, in particular Section 20 which states:

“Limit treatment of yourself or members of your immediate family to minor or emergency services and only when another physician is not readily available; there should be no fee for such treatment.”

Professional Standards

1. Physicians must refrain from treating themselves, family members or anyone with whom a physician has close personal or emotional involvement.There are limited circumstances where the risks associated with treatment in this context are either minimal or are outweighed by the benefits of providing the treatment:
   1. providing infrequent treatment for minor conditions when there is no one else readily available; and
   2. in emergency situations where there is no one else available or qualified to do so.
2. It is not acceptable to conduct an independent medical exam for a friend or family member, as doing so would represent a clear conflict of interest.
3. Physicians must not prescribe the following medications for themselves or family members: Narcotics, controlled drugs, psychotropic drugs, or any drugs that are addicting or habituating.
4. Ordering bloodwork or other diagnostic tests for oneself or family members is not permitted, and can lead to issues with continuity of care and patient safety. Monitoring the results of a blood test or adjusting dosages is also not permitted.

Guidelines

The following guidelines assist in meeting the professional standards.

Determining whether a personal relationship should preclude a physician-patient relationship:

A friendship or emotional relationship can arise within an existing physician-patient relationship.  If this occurs, the physician should consider the impact the personal relationship could have on the quality of care and, where necessary, take steps to mitigate the effects. This could include limiting the scope of treatment provided and referring the patient for particularly sensitive or complicated conditions.  In certain circumstances, it may be prudent for the physician to stop treating that individual.

Physicians may wish to ask themselves the following questions to help evaluate the emotional nature of a relationship and the impact that emotional involvement may have on the quality of care that can be provided.  If the answer is “yes” to any of these questions, the individual probably falls within the definition of “family member” and the physician should refrain from treating the individual, subject to the exceptions described elsewhere in this document.

1. If this individual were my patient, could the personal relationship affect my ability to recognize and act in his or her best interests?When a physician has an emotional relationship with a patient, the physician’s own needs and interests may undermine the physician’s capacity to focus on the patient’s best interests. As a result, the physician may be more inclined to over-treat or under-treat, or may not present all available treatment options to the patient. The physician may also be more inclined to accede to inappropriate patient requests, such as demands for medically unnecessary tests or habituating drugs.
2. Would I be too uncomfortable to ask the questions necessary to make a proper diagnosis, particularly on sensitive topics?A personal relationship can give rise to unconscious, preconceived notions about an individual’s health and behaviour. These preconceptions can affect quality of care, because physicians may not ask questions or seek information that could inform or even alter the diagnosis or subsequent care.  Similarly, patients may intentionally or unintentionally leave out sensitive but important information when discussing their medical history, activities or symptoms.
3. Would I be able to allow this individual to make a decision about his or her own care that I disagree with?Respect for patient autonomy is central to the provision of ethically sound patient care. In order to be autonomous, patients must be able to make free and informed decisions about their health care. When there is an underlying personal relationship between the physician and the patient, the physician’s opinion may unduly influence the patient’s decisions. In addition, the patient may be reluctant to seek a second opinion or decline a recommendation for fear of offending the physician.
4. Could the personal relationship affect my ability to be clinically objective?When a physician treats a family member, professional boundaries are at risk of being blurred or crossed. This can influence the physician’s ability to make objective clinical decisions and provide advice unaffected by the physician’s own feelings. The physician may also fail to recognize conditions or patient needs that are outside of his or her area of knowledge or expertise, or neglect to refer where appropriate.
5. Could the personal relationship with this individual make it more difficult for me to maintain patient confidentiality or make a mandatory report?Confidentiality may be harder to maintain and may be at greater risk of being breached because of the physician’s personal interest in the patient’s well-being, or because other family members insist on knowing “what is going on”. Conversely, a physician may be more reluctant to make a mandatory report (e.g., of an impairment affecting the patient’s ability to drive) when they have a personal relationship with the patient.
6. Could I establish and maintain a proper physician-patient relationship if I were to treat this individual?When treating family members, there may be an expectation that care will be provided outside the context of an established physician-patient relationship and outside the physician’s regular place of work. This can affect the physician’s ability to obtain informed consent, conduct a complete and proper assessment and maintain proper medical records.