Treating friends poses both risks and compromises

What are the ethical guidelines for deciding whether to treat a patient who is or has become a friend? If a doctor must treat a close or casual friend in a rural setting or a health care shortage locale, for example, how can the inevitable ethical compromises be minimized?

Reply: Let's be honest. In the course of our practice, we have treated some patients differently from others. Maybe it was your nurse's son. Maybe it was a "VIP" such as a large donor to your institution. Or maybe it was another physician in your community. Like the rest of us, I am sure you felt somewhat conflicted.

Though permissible in some circumstances, caring for patients on the borderline between friend-acquaintance and patient is fraught with ethical land mines. On the other hand, friends come to us voluntarily for care. What are we to do? Because it is a common problem, I'd like to try to examine some of the issues involved and seek a sensible resolution.

First, what degree of familiarity should preclude you from treating someone? It is clearly wrong to have as a patient someone you are dating. Indeed, if you are going to have a romantic relationship with a patient, you must "fire" that patient from your practice and limit your relationship to one sphere: friend. (Even this may be suspect, given the power difference between patient and doctor.)

But dating is just one point on the continuum of relationships, which can range from pursuing someone romantically to being friends or colleagues, accepting an invitation to dinner or receiving a bottle of wine in the mail for Christmas. The whole spectrum deserves consideration.

When I see a friend or colleague as a patient, I'm both doctor and friend (or colleague), and the dual role may lead me to do too much or too little. On the one hand, I may pursue investigations to the nth degree to avoid an error in diagnosis or treatment; I'm too invested in the outcome of this patient. My attitude may cause me to order unnecessary tests, with the patient bearing the attendant risk. For example, I may order a stress test on a low-risk colleague or friend -- just to be sure. The result is a false positive, which leads to an invasive cardiac catheterization.

On the other hand, I may have so great an emotional connection with the patient that I do too little. I may avoid potentially painful procedures that I would do if I were guided by more objective clinical judgment. I may perform a lumbar puncture for an "ordinary" patient with a headache and fever without a second thought but may be loath to do one on a friend. Friendship can cloud our judgment.

Put in ethical terms, when we treat a friend, we risk compromising beneficence and nonmaleficence by both our action and our inaction. More immediately, we also violate the principle of justice, which states, in part, that similar cases should be dealt with in a similar manner. Like it or not, our emotional or social ties to the patient most likely will change how we treat friends. We may move the patient to the head of the waiting list for a procedure, make an extra phone call to circumvent barriers to care or prescribe a drug, such as narcotics for pain, that we might not ordinarily do. (Be honest, you've done one of these.)

Does this mean we cannot care for friends? That we have to treat all patients dispassionately? There are several answers. First, if you are in a rural area, it is likely that your patients also will be your friends: Neither you nor they may have any (viable) choice. In that case, the patient's need for care may trump the prohibition against treating people close to you.

Second, there is some wiggle room within the principle of justice. Despite being ethically admirable, it is impractical to expect us to treat every patient the same, even if we wish to. We bring our own prejudices and life experiences to each patient-physician relationship. It is clear from the literature that we spend more time with patients who are similar to us, and that many patients self-select a physician based on the physician's race and gender. This does not mean that we should be blind to the principle of justice. We should try to recognize our own biases and correct for them to the best of our ability. But it is unlikely that we can ever treat everyone exactly the same.

So we come back to the question of where to draw the line when caring for friends and other "special" patients. Let's examine some scenarios. If it is a family member or someone close, it is not likely that we can separate our feelings from our judgment, so we should refer this patient to a colleague (although I am sure we have all treated family members for minor illnesses). With regard to friends and others, if it doesn't feel right or you have misgivings, there is probably something wrong: Refer the patient to a colleague.

But feeling comfortable treating a friend doesn't automatically give you a pass. In fact, it should probably cause you to worry more. It may be that you don't recognize the conflict. You have to make the situation clear. You must let your friends know that you may not be able to be dispassionate and that you may compromise their care based on the lack of objective judgment. If the friend is willing to accept this, it is his or her right to do so. But then an additional burden falls on us as physicians.

We must be sure to have a comprehensive discussion with this patient about the various options available for care and not take our friend's trust in us as a license to choose the course we feel is best. Though we should have these discussions with every patient, it is even more important with friends. This will allow a greater degree of shared decision-making, minimizing the bias that we bring to the relationship.

Although we should avoid it, we will almost inevitably end up treating a friend. I hope this piece has put the medical treatment of friends in a framework that is easily applicable to helping us maintain ethical practice.

Mark A. Graber, MD, professor of emergency and family medicine at the University of Iowa Carver College of Medicine in Iowa City