Consider ethics, patient rights before treating your immediate family
■ Should patients be "all in the family"?
Your brother-in-law asks for a prescription for an antidepressant. How should you respond?
Reply: Do we physicians treat our family members? Apparently, we do. A 1991 study showed that 99% of 465 physicians surveyed had requests from family members for medical advice, diagnosis and treatment.
Family members included spouses, children, parents, siblings, nieces, nephews, in-laws, aunts, uncles and cousins. Eighty-three percent of physicians had prescribed medication for a family member, 80% had diagnosed medical illnesses, 72% had performed physical examinations, 15% had acted as a family member's primary doctor, and 9% had performed surgery on a family member.
Twenty-two percent of physicians in the study fulfilled a family member's request about which they felt uncomfortable.
Why do physicians treat family members? Some physicians feel a sense of responsibility to family. Others reported reasons such as convenience, cost and accessibility. Sometimes it is simply a matter of urgency.
But should physicians treat family members? Interestingly, the American Medical Association in its initial, 1847, "Code of Medical Ethics" addressed treatment of physicians' families when it said of the physician, "the natural anxiety and solicitude which he experiences at the sickness of a wife, a child, or anyone who by the ties of consanguinity is rendered peculiarly dear to him, tend to obscure his judgment and produce timidity and irresolution in his practice."
The physician of today certainly experiences the same anxiety and solicitude at the sickness of one "dear to him" -- or her -- as did his/her counterpart a century and a half ago. In our current AMA "Code of Medical Ethics," Opinion 8.19 states that "physicians generally should not treat themselves or members of their immediate families."
The opinion goes on to warn that professional objectivity may be compromised when treating family or self and thus affect the medical care being given. When my nephew was 3, for example, I felt a very small node in his posterior cervical chain. Even though I was not his doctor, I suggested to my sister that he needed evaluation as soon as possible. Of course I (an adult pulmonology fellow at the time) was convinced he had a catastrophic illness. He did not. Sometimes we as physicians gravitate straight to the worst condition on a differential diagnosis list when it comes to family. Other times, because we are so accustomed to routine complaints that are not signs of serious illness, we may underestimate the importance of a family member's symptom. And personal feelings may unduly influence our judgment and actually interfere with a family member's medical care.
There is often a dynamic tension between physicians' personal and professional roles when it comes to the medical care of a family member. Just last year, authors of an Annals of Internal Medicine article reviewed instances from their own experiences and concluded that in some cases involvement was not helpful and was possibly harmful, while in others it was beneficial. In none of their cases did the physician act as the primary physician for the patient-relative.
The authors also suggest that there are potential problems with physicians' participation in loved ones' care to any degree -- whether low risk (explaining medical information to a family member), medium risk (refilling a medication previously prescribed by the primary physician) or high risk (ordering tests or doing procedures).
Opinion 8.19 also points out that when the patient is a family member it may be difficult to address sensitive topics. Some physicians may omit sensitive or intimate areas in history taking or aspects of physical examination. Likewise, the patient may be hesitant to submit to parts of the physical examination or to disclose personal information.
Finally, when treating family members, physicians may be tempted to address problems that are beyond their expertise or outside their training, when doing so can cause them discomfort and potentially harm the patient.
Ethical tenets of autonomy and informed consent are likely to be easily compromised. Family members may feel as though they are offending the physician-relative, if, for example, they refuse a particular recommendation. And the physician may be hard-pressed to respect the right of a patient-relative to refuse when, in his or her professional judgment, the recommendation is in the patient's best interest. Here again, I offer a personal example. My sister has asthma and, though I am not her doctor, I am a pulmonologist. It takes great effort on my part to respect some of her choices for "self-medication."
Family members of physicians have the same rights as any patient, including the right to informed consent, meaning that the patient must hear all appropriate information about the nature of a procedure, its risks, benefits and side effects and reasonable alternatives to the suggested treatment. Any patient, even a family member, then has the right to ask questions, to refuse the physician's recommendation and to understand the consequences of his or her choices. The informed consent dialogue might very likely be nonexistent or subpar if a physician were to treat a family member.
While Opinion 8.19 of the "Code of Medical Ethics" advises that "physicians generally should not treat themselves or members of their immediate families," it also states that "in emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available." And even though physicians should not be the primary care physician for a family member, sometimes routine care is acceptable for short-term, minor problems. This opinion language leaves room for interpretation, so discernment on the part of the physician is essential in such circumstances.
Deciding whether to treat family members and, for that matter, self or colleagues, is not a new dilemma for physicians. Yet these aspects of medical practice are not often taught or discussed in medical venues. Such discussions should be part of formal medical training for students, housestaff and practicing physicians. The ethical, emotional and competency concerns that treating relatives raises should be talked about during such training. The AMA Council on Ethical and Judicial Affairs soon will issue an opinion on peers as patients. Watch the online PolicyFinder and the next print edition of the "Code of Medical Ethics" for this opinion.
Although it may seem impossible to separate ourselves from the physicians we have become, at times it may be more helpful for us to be a good spouse, parent, child, sibling, grandparent, aunt, uncle, niece, nephew, cousin or in-law to the patient rather than a physician.
Sharon Douglas, MD, pulmonologist; associate professor of medicine, associate dean for VA education, ethics instructor, University of Mississippi School of Medicine; member, AMA Council on Ethical and Judicial Affairs