Dialogue: Trust in your doctor demands detachment

GILLIAN WHITE* says that sexual intimacy always violates the boundaries of a professional relationship.

Morgan Fahey, general practitioner and civic councillor, has confessed to sexual violation of patients over many years and society is stunned such behaviour could have been perpetrated.

However, in 1993, when I studied the prevalence of sexual contact between New Zealand doctors and their patients, seven GPs said they had had sexual contact with current patients.

Six of these knew of other GPs who had also engaged in sexual contact with patients. In addition, four GPs said they had engaged in sexual contact with former patients.

Although 90 per cent of the GPs surveyed indicated that sexual contact with a patient was never permissible under any circumstances, more than a third indicated that if they knew a colleague was engaging in sexual contact with a patient, they would do nothing.

To be in a position of confidence and trust, and to possess specialised knowledge, is to be in a position of power. Because of this, a person requesting professional services is especially vulnerable.

There is considerable evidence of harm when sexual intimacy occurs in situations where there is an established vulnerability resulting from an asymmetrical power relationship, and where professional boundaries are violated.

Harm associated with boundary violations, specifically sexual exploitation, relates to deeply held beliefs about power, sex and gender which affect both the individual psyche and the way societies construct professional ethics.

Boundary violations can be deliberate or accidental and are often intuitively felt rather than empirically observed.

People who are given a mandate of authority and responsibility are expected to be morally conscious, ethical and trustworthy. Prescribed boundaries serve to protect the vulnerable from those in authority who fail in that duty.

A professional relationship where one person accepts the trust and confidence of another in return for the knowledge and skill which enable the professional to act in the best interest of others demands that the professional takes on certain responsibilities and gives away certain options.

Expecting the vulnerable partner to define and keep the boundaries constitutes role reversal and places the professional's needs first. Sexual intimacy is an extreme boundary violation for which the professional has to take responsibility, even where it is not self-initiated.

The issue of responsibility is often raised when allegations of sexual exploitation are discussed in situations where there appear to be two consenting adults.

Monica Lewinsky, for example, could have been said to have consented to a sexual intimacy with Bill Clinton, the private man, and, therefore, was not sexually exploited.

But she could not have given full informed consent to the President of the United States. In taking on the role of President, Clinton has a clear duty of care for the citizens of his country. He has to be trusted.

Dr Fahey and others like him fail in their duty to protect patients. He broke his trust and his pastoral responsibility, both as a doctor and as a city councillor. In his case, it is indisputable that a moral and ethical boundary has been violated.

Taking advantage of a person's dependence on a trusted figure can be viewed as rape and where the figure symbolises a parent, as in the case of some health professionals, as incest. Violation of trust results in isolation and denial when victims are either sworn to secrecy or convinced they will not be believed.

Although professional boundaries are often understood instinctively, it is not always clear who the keeper of the boundary is. Prescribed professional boundaries serve to protect the professional as well as being regulatory, hence professional boundaries are also a form of control.

That a profession requires a form of control over its members is evidence that at some time, and probably more than once, harm has resulted from an abuse of the professional relationship.

A profession is defined by having its own body of knowledge and skills within a set of values supported by a code of ethics. The doctor-patient relationship, for example, is a special type of fiduciary - or trusting relationship - in that it demands both intimacy and detachment.

Fiduciary relationships have an inherent power differential where the professional accepts the confidence and trust of the client and, in doing so, gains personal knowledge of the client without having to reveal anything about him or herself.

A successful medical encounter lies in the bond between doctor and patient. Unnecessary or unexplained sexual contact by medical practitioners can contribute to an invalidation of normal, healthy, female sexual functions, and women can feel abused even where the sexual contact is agreed to.

This derives from violation of the boundary where the doctor overtly or covertly enters the relationship from a position of power. This is why New Zealand women confronted Dr Fahey.

The principle of trust which underpins professional ethics, and the power which is invested in the professions, are meant to be used by professionals to benefit their clients and not for their own self-gratification.

This is the basic tenet of the injunction that medical practitioners maintain professional boundaries in the doctor-patient relationship. Caveat emptor or the laws and mentality of the market place should not prevail. When sexual abuse is exposed, relatives, friends, clients, members of the profession, the social community, and even the country, also require healing. Where a doctor, or even the President of the most powerful nation responds sexually to a client, employee, staff member or person in their care, a situation of sexual abuse can be conferred on the premise that the other party can never give informed consent.

A role conflict has blurred the boundaries. The gold standard for any person with obligations under a duty of care is primum non nocere (first do no harm).

There is an established relationship between power and sex which endures wherever there is tolerance towards sexual exploitation of the vulnerable by those with power. Where a code of silence prevails, long-term harm will occur and everyone is a victim.

* Dr Gillian White is a senior lecturer at the school of health sciences at Massey University, Albany.