FIGURE
Has a patient ever given you an expensive gift? Have you ever shared a deeply personal aspect of your life with a patient? If you answered yes to either of these questions, you're not alone. Because the clinical setting has some vague boundaries, ethical dilemmas can haunt us. The ambiguity of many situations makes us feel alone, and we are without clear professional ethical codes to guide us.
While few of us are confused about ethical questions related to confidentiality, improper relationships with patients, and taking financial advantage of a patient, gray ethical areas exist.
Presents from Patients
Old ethical rules for professional conduct view gift giving as a transference issue. The patient may confuse the clinical relationship with significant people in his or her past. In this situation, if you accept the gift, you risk harming the therapeutic relationship. Patients who give valuable gifts may also be trying to bribe the clinician into having an unhealthy relationship outside the clinical setting.
Conversely, accepting an expensive gift may give patients great joy, enabling them to celebrate their success and appreciation. If you reject the gift, you may jeopardize the therapeutic relationship, as the patient may feel personally rejected.
When faced with an ethical dilemma, we can better respond to our patients by thinking in terms of safeguarding them from exploitation. Ethical rules are designed to protect vulnerable patients. Ask yourself, "Does the gift increase the patient's vulnerability?"
Self-Disclosure Decisions
We expect our patients to disclose their vulnerabilities and expose their bodies while we maintain an aura of confident competence and professional concern. Although we collaborate with our patients on formulating the best plan of care, most patient/clinician encounters still have a degree of inequality. When is self-disclosure helpful to patients and when is it self-serving and non-therapeutic?
Old ethical guides posit that self-disclosure risks a convoluted transference-countertransference dynamic: The old relationship patterns are played out in the patient/clinician relationship. We risk damaging the privacy and dignity of our patients if we share our own personal problems.
If disclosing our personal problems meets our own needs, then we're hardly helping the patient. But, telling a short, personal story that has a point or moral can help patients.
In actuality, it's our own humanness, and not our professional image, that's most helpful to patients. By balancing what's best for patients with our best instincts, we'll give our patients a valuable gift: caring respect.
In Memory of Barbara Bates, 74, Physician, Educator, Author, Historian
Barbara Bates, MD, FACP, a well-known professor to medical and nursing students, author, and historian, died December 18, 2002, of Alzheimer's disease at her home in Bryn Mawr, P.A.
A native of Auburn N.Y., Dr. Bates earned her BA at Smith College in 1949, and completed medical studies and residency training at Cornell University Medical College in New York City. She was the recipient of several honors, including membership in the medical honor society Alpha Omega Alpha, and her well-known book "A Guide to Physical Examination and History Taking," first published in 1974, continued under her direction through 7 editions, and is still a leading text in the field.
Dr. Bates' long career focused on improving the quality and distribution of health care through patient care, teaching, interdisciplinary innovations, research and writing. In the late 1960s, she helped conceive and develop the then new role of nurse practitioner, working to improve public access to health care by encouraging greater collaboration between physicians and nurses and expanded practice opportunities for nurses.