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Ethical Obligations and Principles

Overview | Clinical Scenarios | Additional Tips | References
By Jacob M. Appel, MD, JD

OVERVIEW

Definition

The physician-patient relationship results from mutual consent in most circumstances. It may be terminated by either physician or patient, although a patient should be given adequate opportunity to obtain alternatives for medical care. During the course of the relationship, the provider is said to have a fiduciary duty to the patient, requiring the provider to serve the patient’s interests. A physician-patient relationship imposes many obligations upon the provider that distinguishes these relationships from social interactions. These include confidentiality, mandatory reporting, record keeping, maintaining boundaries and providing treatment within the standard of care. In addition, a psychiatrist may have an obligation to serve the public welfare or protect the safety of third parties, such as through Tarasoff warnings, even over the objections of their patients. Psychiatrists, when appropriate, should delineate such duties in advance and should inform the patient of their actions (e.g. mandatory reporting) if it is safe to do so.

Context

In taking any action related to a patient, the provider should be certain his intent is to serve the patient’s interests. Uncertainty often arises at the start or conclusion of a physician-patient relationship. In the course of the therapeutic relationship, conflict may arise around such issues as fees and scheduling.

Common Sources of Conflict

  1. A psychiatrist sees a patient “in consultation” on a one-time basis, but the patient falsely assumes this means the provider will continue to provide care.
  2. A patient may resist efforts to terminate a relationship.
  3. A patient insists upon appointments at a time when the provider is unavailable.

* Some physicians—such as those doing forensic or workers’ comp evaluations—do not have a fiduciary duty to patients.2
* It is important that physicians explain the nature of their responsibilities to those they are evaluating in such circumstances.

CLINICAL SCENARIOS

Scenario #1: A psychiatrist’s cousin approaches him at a family event and asks for a favor; the cousin explains that his own psychiatrist is away for the week, and that he has run out of his antidepressant. He asks for a 7-day prescription to tide him over. How should the psychiatrist handle this situation?

  1. The line between social relationships and professional relationships is not always readily apparent. Both social connections and strangers may ask physicians for guidance outside the clinical setting.
  2. As a general rule, such requests should be politely refused.1
  3. Reasons to refuse such requests include inadequate information regarding the requesting individual’s health medical history, an inability to document actions taken, the risk of inadvertently establishing additional expectations, and liability that may prove beyond the scope of one’s insurance.
  4. It is essential to clarify in social relationships that one is not the patient’s physician and it may be prudent to suggest that the individual consult an appropriate physician.

Scenario #2: An outpatient psychiatrist seeks to terminate care with a patient who is consistently disruptive and demanding and has also failed to pay for sessions for nearly eight months although he has the financial means to pay. When the provider broaches the subject of termination, the patient threatens to sue and states he refuses to receive care elsewhere. How should the provider handle this?

  1. The physician-patient relationship is generally a voluntary one that requires the ongoing consent of both parties. This principle was clearly established in the seminal case of Hurley v. Eddingfield (1901). Barring certain rare circumstances, a provider cannot be compelled to treat a patient indefinitely.
  2. A psychiatrist seeking to terminate care should inform the patient of this decision and ensure they have adequate time to obtain care from another provider. Barring unusual circumstances, six months is generally the outer limit of how long a patient should be afforded before termination.
  3. Patients who are cognitively limited or otherwise incapable may require assistance in securing alternative providers.

ADDITIONAL TIPS

  • Accurate and sufficient documentation is a key feature of the physician-patient relationship.
  • In many jurisdictions, failure to maintain a medical record may prove grounds for discipline.
  • Documentation is a useful tool for communicating with other providers.
  • In legal settings, such documentation serves as evidence to explain both the physician’s conduct and its rationale.

REFERENCES

  1. Adler EL. Why physicians should steer clear of treating family members. Physician’s Practice. August 14, 2013. Available at: https://www.physicianspractice.com/view/why-physicians-should-steer-clear-treating-family-members 
  2. Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997 Apr;154(4):448-56. Available at: https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.154.4.448

Additional Reading

  1. “Patient-Physician Relationships,” “Code of Medical Ethics Opinion 1.1.1, American Medical Association. Available at: https://www.ama-assn.org/delivering-care/ethics/patient-physician-relationships
  2. “American Medical Association,” Code of Medical Ethics: Patient-physician relationships. Available at: https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-patient-physician-relationships
  3. Dorr Goold S, Lipkin M Jr. The doctor-patient relationship: challenges, opportunities, and strategies. J Gen Intern Med. 1999;14 Suppl 1(Suppl 1):S26–S33. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496871/
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