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Case example
Dr. George Gayle has just completed the final stage in his formal medical training, a fellowship in medical oncology, and has joined a local multispecialty medical practice. He is a devoutly religious man and is a leading member of a large Christian congregation. Because his religious faith is such a central part of his life, Dr. Gayle would like to incorporate his spiritual beliefs into his professional practice.
Dr. Gayle informs his physician colleagues that he intends to address spiritual issues with his patients in several ways, including asking all of his patients about their own spiritual beliefs and practices, inviting patients to pray for healing with him, encouraging patients to take advantage of the health benefits of prayer and of other religious practices, inviting patients to visit the Sunday school course he teaches, and helping patients with serious illness understand that there is meaning in life and hope for the future. May he engage in these activities with his patients?
Over the past two decades, professionalism has become a major topic of discussion in medicine and health care. Commentators warn that the increasing commercialization and bureaucratization of health care is undermining the professionalism of physicians and other health care professionals.1 In response, professional associations have adopted formal statements pledging support for principles of professionalism, and professional schools have expanded professionalism instruction for their students.2 This chapter will examine the concept of professionalism and consider its moral significance in health care. It will then focus on one specific application of the concept of professionalism, namely, the identification and enforcement of professional boundaries.
Conceptual issues
Despite general agreement about the importance of professionalism in health care, there is considerably less consensus on the meaning of this term. In its most general sense, ‘professionalism’ is defined as “the conduct, aims, or qualities that characterize or mark a profession or a professional person.”3 As this definition indicates, understanding what is meant by professionalism requires a prior understanding of the concepts of a profession and a professional. But these latter concepts have many meanings, and they are associated with many kinds of “conduct, aims, and qualities.” Consider, for example, the following ways in which a person may be considered a professional:
1. The person receives payment for his work, e.g., a professional painter, a professional basketball player.
2. The person is licensed or certified to perform his work, e.g., a licensed electrician.
3. The person has had an advanced education, in a “professional school,” e.g., an architect.
4. The person engages in intellectual rather than manual labor, e.g., a university professor, a research scientist.
5. The person belongs to a group that creates and enforces its own standards of competence, e.g., an attorney.
6. The person belongs to a group that has sole control over a socially valuable activity (a “professional monopoly”), e.g., a certified public accountant.
7. The person “professes” (that is, publicly affirms) special duties and high moral standards, e.g., a priest or minister.
All of the above “professional criteria” apply to physicians, and most of them apply to other health care professionals, such as nurses, pharmacists, and physical therapists. Though all these criteria reflect common uses of the terms ‘profession’ and ‘professional,’ they differ markedly in their moral significance. Some criteria, like embracing high moral standards, are morally praiseworthy; others, like advanced education and intellectual labor, are morally neutral; and still others, like self-regulation and a professional monopoly, may be morally questionable if they promote the interests of professional groups at the expense of others.
To make substantive claims about the moral importance of professionalism, therefore, one must consider not only the specific profession in question, but also identify the morally significant features of that profession. Let’s turn, therefore, to consideration of the distinctive moral features of professionalism in medicine and health care.
The moral significance of professionalism in health care
Is there something morally distinctive about medicine and health care that confers special urgency or importance on professionalism in those areas of human activity? Edmund Pellegrino, a leading physician, scholar, and educator in the field of bioethics over the past half-century, has made a persuasive case for the moral significance of professionalism in health care.4 Pellegrino identifies five characteristics of the relationships between health care professionals and patients that give those relationships special moral import:
1. Health care professionals care for people who are vulnerable; patients are usually sick, injured, or suffering, and so are dependent on the knowledge and skill of their professional caregivers.
2. Health care professionals protect and promote fundamental human values of life, health, physical and mental functioning, and relief of pain and suffering.
3. The professional–patient relationship requires a distinctive kind of intimacy in which patients disclose confidential personal information and give health care professionals access to private parts of their bodies for examination and treatment.
4. Due to their vulnerability, patients must trust in the knowledge, skill, and good intentions of professionals, and professionals must rely on the trust of their patients in order to care for them effectively.
These five characteristics, Pellegrino argues, make health care a morally distinctive enterprise. Recognizing them can help us to understand appeals to professionalism in health care as efforts to keep professionals true to their commitments to act for the good of their patients and to refrain from exploiting patient vulnerability. These professional commitments impose limits, or boundaries, on appropriate professional behavior.
Pellegrino emphasizes the moral obligations of health care professionals, but he also recognizes the moral agency of both patients and professionals.5 Just as respect for patients imposes obligations on professionals, so also can respect for the moral agency and integrity of professionals impose limits on the demands that patients may make on their services. The remainder of this chapter will focus on one application of professionalism in health care, that is, the recognition and enforcement of professional boundaries. We will consider how these boundaries create both obligations and privileges for health care professionals.
Professional boundaries in health care
Laws, regulations, professional guidelines, and institutional policies have established a variety of professional boundaries in health care to define and encourage appropriate behavior, and to discourage or prohibit inappropriate behavior, in therapeutic relationships. Some boundaries are designed to protect patients from harm, such as exploitation or substandard care. Other boundaries are designed to protect the health care professions and individual professionals from harm, such as loss of a profession’s identity, or violation of an individual professional’s moral integrity. Because professional boundaries impose limits on the behavior of both clinicians and patients, however, they are also subject to criticism and challenge. Some recommended boundaries may, for example, unduly interfere with personal freedom of action and association. Other boundaries may limit patient access to needed services.
Boundary rules have been proposed and adopted to guide a wide variety of professional activities. General boundary rules, moreover, may apply in different ways in specific contexts. To account for these different applications, we can make use of a distinction between boundary crossings and boundary violations proposed by Nadelson and Notman.6 A boundary crossing is a morally permissible action that does not comply with a general boundary rule. A boundary violation is a morally objectionable failure to observe a professional boundary. Consider, for example, the general boundary rule against physical contact between physicians and patients except as needed during physical examination and treatment. Holding a fearful patient’s hand while disclosing a diagnosis of a serious illness may be considered a morally benign boundary crossing, while sexual touching of an anesthetized patient would be a morally objectionable boundary violation.
In the remainder of this chapter, I will examine four major categories of professional boundaries in health care: “Personal Boundaries,” “Commercial Boundaries,” “Inter-professional Boundaries,” and “Integrity Boundaries.”
Personal boundaries
Professional boundaries in this category are the most widely recognized and addressed in public policy and in the medical literature. The rationale for these boundaries is to establish a clear distinction and separation between the professional relationships clinicians have with their patients and the personal relationships they have with family and friends. This separation is viewed as essential for several reasons. It calls attention to the very different purposes and goals of these two kinds of relationships, and to significant risks of harm if the two kinds of relationship are combined. Vulnerable patients who are dependent on a professional’s care may, for example, be subjected to sexual exploitation by an unscrupulous professional, without clear rules prohibiting sexual contact between patients and professionals. Even if there is no intention to exploit a patient, combining professional and personal relationships may adversely affect the quality of care. For example, the emotional bond between a professional and a close family member may hamper the professional’s ability to assess the family member’s health condition objectively and treat it appropriately. Personal boundaries also protect professionals from patient efforts to pry into a professional’s personal life or to enter into a personal relationship with the professional.
Examples of personal boundaries, in addition to the prohibition of sexual relations between patients and professionals and treatment of immediate family members, are rules against entering into business agreements or partnerships with patients, rules against disclosing personal problems to patients, and rules limiting acceptance of expensive gifts from patients.7 While small gifts from patients may be a morally benign expression of a patient’s gratitude for a professional’s good care, expensive gifts are more likely to be a kind of bribe or “quid pro quo,” with the expectation of special favors from the professional. Commentators also warn about the potential for personal social networking sites like Facebook to blur the boundary between personal and professional relationships, and they advise against professionals entering into online “friend” relationships with their patients.8
Although the above-mentioned personal boundaries are well established in health care, there are also controversial questions about their limits. Consider the following example. Laws and professional standards in most jurisdictions prohibit sexual contact between professionals and their patients. Should that prohibition extend to sexual contact between professionals and former patients? Potential for exploitation, though diminished, may still exist, but the parties may feel great affection for one another and claim that they should have the freedom to enter into an intimate personal relationship. The AMA Code of Medical Ethics addresses this question by asserting that physicians must, at a minimum, terminate the physician–patient relationship before initiating a dating, romantic, or sexual relationship with a patient and adding that “sexual or romantic relationships with former patients are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the previous professional relationship.”9
Another complex question for this category of professional boundaries is the role of spiritual and religious issues in the professional–patient relationship.10 On the one hand, religion and spirituality are deeply personal domains, and so one might argue that they should not enter into professional relationships in health care. On the other hand, spiritual and religious beliefs and practices may contribute to health and well-being, and so one might argue that a holistic approach to health care should include its spiritual dimension. Analysis of the case described at the beginning of this chapter will examine this question in greater detail.
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