Many medical professionals are approached by family members and friends for medical advice, consultations, and treatment. This situation probably arises because the medical professionals are known so the family members or friends may feel more comfortable or expect a certain degree of special treatment and prompt care. This also means that the practitioner takes on the role of a family member or friend and the professional practitioner role, creating a dual relationship. The question is, however, whether it is acceptable for a family member or friend to be a patient and the implications thereof.
Benefits to the patient being treated by a practitioner who is a family member or friend
Patient autonomy dictates that competent adults have the right to make informed decisions about their own medical care. This includes the right to choose a particular medical practitioner for service, provided that such choice is not contrary to the ethical standards applicable to the medical practitioner. This means that a patient is entitled to choose a practitioner even though that person is a family member or friend.
It can also be beneficial for medical professionals to treat family members or friends as there is already familiarity and the medical professional is a trusted confidant. The consultation and consent-taking process may also be easier considering that in all likelihood the patient’s background is already known to some degree. Another factor is a possible reduction in medical costs, which is beneficial to patients.
The disadvantages that can arise
There are also a number of disadvantages that can arise from the nature of this dual relationship. The medical practitioner will no doubt be invested in the relationship over and above his or her professional role. This is not necessarily a problem unless such investment compromises the practitioner’s professional and clinical judgement.
Medical practitioners have to respect the right of patients to be fully involved in decisions about their treatment and the right of patients to refuse treatment or to seek a second opinion without prejudicing their future treatment. These rights may be transgressed if the practitioner chooses not to afford family members or friends the same respect as they would another patient.
Another factor to consider is that family members or friends may withhold certain confidential medical information and this is not conducive to the doctor-patient relationship.
Medical practitioners also need to exercise caution in protecting all personal and confidential information acquired in the course of their professional duties, including information about family members and friends. This will also apply if family members or friends who are patients disclose confidential medical information outside of the professional setting, such as at a gathering, as this could be in transgression of the rules and guidelines on confidentiality.
Record keeping
Medical practitioners need to ensure proper record-keeping, to the same extent as they would for any other patient in accordance with the Health Professions Council guidelines. The records must show that the practitioner acted in accordance with ethical practice and must justify any assessment, investigation, or treatment. These records could also assist the practitioner to defend a decision made during his or her treatment of the family member or friend, should it be questioned at a later stage.
What if there is an adverse outcome when treating a family member or friend
Should the treatment or diagnosis result in an adverse outcome, the family member or friend has the right to act against the practitioner in the same way that he or she would if the practitioner was not a family member or friend. This includes lodging a formal complaint to the Health Professions Council or instituting a civil claim. This can impact both personal and professional relationships negatively.
Immediate family members and intimate friends
It is important to draw a distinction between a practitioner’s immediate family members or intimate friends and more distant family members or friends. With the former, it is generally recognised that there is too great a danger of subjectivity, whereas, with the latter, treatment may be deemed ‘more’ acceptable.
A practitioner’s children, spouse, or parents are all examples of close relatives. In all likelihood, the doctor is emotionally invested and this is likely to impact his or her objectivity and cloud his or her judgement. Another consideration is that the immediate family member or intimate friend might feel reluctant to disclose the full particulars of their problem or to receive examinations that are sensitive or intimate in nature. The immediate family member or close friend may even feel obliged to comply with the instructions of the doctor despite feeling uncomfortable in the situation. The consent process may also be unbalanced as the practitioner might be inclined almost to force his or her opinion onto the patient and this impacts a patient’s right to make a personal healthcare decision.
When a practitioner chooses to treat an immediate family member or a friend, especially if this is on a regular basis, then the practitioner needs to ensure that this is not deemed unethical practice. This is because it may be considered unfair financial gain where the immediate family member’s medical aid scheme is constantly being billed, even if only for materials or dispensary medication.
Despite the aforementioned, it may be acceptable or even necessary to treat a close family member or friend in emergency situations. However, as far as possible a doctor should attempt to refer the person requiring emergency assistance to a colleague.
What is the current position in South Africa on this topic?
Currently, there is no law that prohibits a medical practitioner from treating his or her family members or friends. There is also no mention of this in the current Health Professions Council of South Africa’s Ethical Guidelines for Good Practice in the Health Care Professions.
The last available guideline on the treatment of immediate family members was when the Medical and Dental Professions Board resolved in October 2007 at a Board meeting that it was permissible for a practitioner to treat his or her immediate dependants. It was not, however, permissible for a practitioner to render accounts for services rendered to such dependants, except in the case of laboratory fees and material for which it would be permissible to render an account. It was further mentioned that the expression “material” could be interpreted to include “dispensing of pharmaceuticals”. The aforesaid guideline was never amended or addressed further in the new guidelines or rules.
It is important to note that the above guideline only referred to “immediate family members” meaning dependents of the practitioner, and not to other family members or friends. There is therefore not much guidance in South Africa on this topic.
The American Medical Association adopts the view that generally, practitioners should not treat members of their families as their professional objectivity may be compromised.
The General Medical Council of the United Kingdom advises that, wherever possible, practitioners should avoid providing medical care to anyone with whom they have a close personal relationship. There is no prohibition and the guideline is in place to ensure that practitioners are wary of the potential risks involved. However, the General Medical Council ethical guidance makes specific mention of prescribing any medicine to someone close to the practitioner. The ethical guideline requires a practitioner to make a clear record of such a prescription, mention the relationship and include the reason why it was necessary to prescribe. The ethical guideline also forbids the prescribing of controlled drugs to someone close except in an emergency.
Conclusion
As there is no law prohibiting the treatment of family members or friends and no updated guidance from the Health Professions Council of South Africa, it appears that a practitioner may treat a family member (immediate or not) or a friend and also charge a fee for rendering such professional service. It is, however, important to consider the ethical rules of the Health Professions Council and ensure that the dual relationship will not result in the transgression of either ethical rules or patient autonomy. This will be difficult in practice, as there is a risk of a lack of objectivity, especially in a situation where the practitioner intends to treat an immediate family member (spouse/parent/child).
A practitioner needs to assess each situation individually and also consider whether his or her objectivity will be compromised in any way. My view is that it is advisable to refrain from having family members or friends as patients and only to assist in emergency circumstances. If a practitioner chooses to treat a family member or friend, he or she needs to be able to defend his or her decisions and prove objectivity should his or her actions be brought to the attention of the Health Professions Council. Any complaint will be considered on a case-by-case basis but could be frowned upon.
In conclusion, while it is legally acceptable to treat someone close to you, this can be fraught with difficulties and be questionable ethically. A practitioner needs to ensure that professional care is optimal and in the best interests of the patient. If a practitioner has any concerns about this issue, it is advisable to contact his or her medical defence organisation for advice.
