Papers

Above All, Do No Harm:
Abuse of Power by Health Care Professionals

Kathleen S. Lundgren, Wanda S. Needleman, Janet W. Wohlberg  

Seventeen centuries after physicians were instructed by Hippocrates to “abstain from every voluntary act of Mischief and Corruption,” this early oath remains the foundation for most of the ethical codes of the health care professions.  In this paper, co-authored by a medical ethicist, a psychoanalyst, and a professor of organizational behavior, the ethical, legal and psycho-social reasons for health care professionals to refrain from becoming sexually or emotionally intimate with their patients are examined. The authors argue that it is the power-imbalance between professional and patient that allows health care professionals to exploit or abuse as well as to heal. Well-meaning professionals who wish to avoid harmful relationships with patients must recognize not only this power imbalance but also the inevitability of personal limitations.  Further, professionals must be open to new ideas and remain flexible in the face of the unexpected.

The Origins of Professional Conduct Codes

As early as the 4^th century B.C., physicians were warned to use “self-control” in relationships with their patients (Reiser, Dyck & Curran: 1977, p. 5) and were instructed by the Hippocratic Oath to “abstain from every voluntary act of Mischief and Corruption and further from the seduction of females or males, of freemen and slaves….” (Braceland: 1969, p. 233) Over the past two centuries, codes of professional conduct have evolved to meet contemporaneous needs, such as removing the Hippocratic prohibition against surgery and de-emphasizing paternalism. Western physicians of the 21^st century continue to “trace the foundations of their ethics” to this early oath.  It remains the “dominant ethical document” and the foundation upon which these evolving codes have rested. (Veatch: 1989, p. 7) The Hippocratic Oath contains two aspects, that of duty to the patient and that of covenant with the community. (ibid, p. 5) In relationship to the patient, the health care professional pledges to “work toward the benefit of the sick,” is directed to refrain from administering deadly drugs, is enjoined from disclosing “those things that ought not to be spread abroad,” and is mandated to abstain from engaging in sexual relations with patients.  In relationship to the community, the health care professional pledges to participate in activities for its benefit.

Freud admonished that “the physician…should deny to the patient who is craving for love the satisfaction she demands. The treatment must be carried out in abstinence.” (Freud: 1958, p. 165) In their 1970’s studies, sex therapists Masters and Johnson characterized sexual contact between a psychotherapist and a patient as rape. (Masters & Johnson: 1976, p. 548) And recent court decisions have held that health care professionals must adhere to the standards of fiduciaries. As fiduciaries, they are not allowed to benefit from their positions of power, and they are required to forgo “all personal gratification” in their dealings with patients. (Strasburger et al: 1992) Thus, historically as well as currently, health care professionals have been admonished on ethical and legal grounds to refrain from becoming sexually or emotionally intimate with their patients.

Health care professionals experience much legitimate gratification from their work.  They derive feelings of competency by gathering necessary data, skillfully diagnosing, and appropriately treating a patient.  They gain satisfaction from earning a living while performing humane, complex, and vital tasks.  However, when a health care professional derives gratification from a manipulative, controlling, or threatening relationship with a patient, whether the behavior is of an intimate or sexual nature, such behavior is exploitative and thus violates the ethical and legal obligations of the profession. 

Harriet Spearing: A Case of Professional Abuse

The following scenario, while fictional, has been distilled from the most frequently reported experiences of thousands of victims of exploitation by psychotherapists and other health care professionals.  It illustrates the ways in which unexamined and unchecked ego and other psychological needs may start a professional relationship down a slippery slope and into an abusive relationship.  It also illustrates aspects of abusive relationships that are almost always damaging to patient and therapist alike.

If Dr. X had told Harriet Spearing on their initial visit that part of her “cure” would involve their having a sexual relationship, she might not have returned for her second appointment.  Or, she might have convinced herself that she had misunderstood what he said, that she needed to move beyond her belief that only bad things happen to her, or, desperate for help, she might not have heard him at all. 

Believing in his outstanding credentials and reputation as a leader in his field, Harriet trusted Dr. X, as he told her she must if she was to get well, For the following four years, she clung to his increasingly frequent reminders that she was fortunate to have found him, that no other psychotherapist could cure her, and that she was special to him.  Their one appointment per week increased to two and then four, as her symptoms worsened and she became more dependent on him. 

Harriet’s appointments were rescheduled so that hers was the last of his day. They often were extended to two or more hours.  She was devastated and apologetic when he criticized her behavior or appearance, something he did with escalating frequency.  Many of his comments were sexually charged.  He told her it was normal in the therapeutic process for her to have sexual fantasies about him. Within a week of this suggestion, she began to have such fantasies.  He encouraged her to talk about them and ultimately proposed that they act them out.  He graphically described his sexual fantasies about her and suggested acting them out as well. He told her that if she told anyone about their intimacies, he would have to stop seeing her.

As Harriet concentrated her emotional energy on her relationship with Dr. X, she became evermore isolated from her family and friends, often at his urging.  He told her that her family was toxic and needed to be avoided, that her boyfriend was wrong for her, that her friends were unworthy of her, and that only he could be depended upon to take care of her.  He told her that he would leave his wife to be with her if not for his sickly child whom he could not abandon.

After four years, two of which included physical touching, kissing, and ultimately sexual intercourse, Dr. X told Harriet that she disgusted him and that he would no longer see her, With all of her support systems gone, Harriet was devastated, blamed herself for what had taken place, felt ashamed, and lost her ability to trust herself and others.

The Aftermath of Professional Abuse

Patients who are exploited by health care professionals report serious levels of depression, anxiety, suicidal thoughts or attempts, and dissociation. In addition, exploited patients lose the ability to trust not only others but themselves: They believe it was their lack of clear judgment and inability to protect themselves that resulted in the abuse. As with survivors of rape and incest, they blame themselves for the abuse and are burdened by feelings of guilt and shame.

While it is always the responsibility of health care professionals to set and maintain clear and safe boundaries, even those who care greatly about their patients may be drawn into harmful and exploitative relationships.  They may find themselves moved to do the wrong thing in the face of patients who consciously or unconsciously manipulate them through inducing anger, pity, or other kinds of reactive emotions. It is vital that physicians recognize their own vulnerabilities to patients, including those arising from feelings of insecurity about physical attractiveness, concerns about professional capabilities, or rescue fantasies. Understanding one’s vulnerabilities and being able to frankly discuss the management of them with peers may go a long way toward helping health care professionals keep both themselves and their patients safe.

Some vulnerabilities may lead some health care professionals to objectify and distance their patients.  Such health care professionals fail to recognize their patients’ humanity and vulnerability. They see their profession as a dichotomous “we versus they,” and may become unable to recognize, address, or correct their own potential to abuse power before harm is done. In addition, they may collude with colleagues by denying that exploitation of patients takes place.

At the outset, health care professionals must recognize the power they hold over patients, not only because the professional has the knowledge and ability to treat and cure, but also because the professional is entrusted with personal and intimate information about the patient as material is gathered in the course of treatment.  The late Dr. Franz Ingelfinger, as he was undergoing his own cancer treatment, wrote: “Intrinsic…is the patient’s conviction that his physician not only can be trusted but also has some specialized knowledge…He needs, if the treatment is to succeed, a physician whom he invests with authoritative experience and competence…a physician from whom he will accept such domination.” (Ingelfinger: 1980, p. 1507)

It is this power-imbalance, brought about by the patient’s trust and acceptance of “domination,” that allows health care professionals to exploit as well as to heal. (Wohlberg: 1997)  The well-meaning professional who wishes to avoid a harmful relationship with a patient must recognize not only this power imbalance but also the inevitability of personal limitations and be open to new ideas, remaining flexible in the face of the unexpected.

Virtually every major health care organization has adopted clear guidelines precluding exploitation of patients.  The health care professions should also establish training programs and safe havens for their members where those who are tempted are able to explore their feelings and their behaviors in some way more thoughtful than the current “peer-in-the-hall” consultation.

References

Braceland, F. (1969) Historical perspectives of the ethical practice of psychiatry. American Journal of Psychiatry. 126:233.

Freud, S. (1958) in The Standard Edition of the Complete Psychological Works of Sigmund Freud, James Strachey, ed., London:The Hogarth Press, v.12, p. 165.

Ingelfinger, FJ. (1980) Arrogance. New England Journal of Medicine, 303:1507.

Masters, W. and Johnson, V. (1976) Principles of the New Sex Therapy, American Journal of Psychiatry. 131:548 

Reiser, SJ, Dyck, AJ, & Curran, WJ. (1977) Ethics in Medicine: Historical Perspectives and Contemporary Concerns. Cambridge, MA: MIT Press, p. 5 

Strasburger, LH, Jorgenson, L, and Sutherland, P. (1992) The Prevention of Psychotherapist Sexual Misconduct: Avoiding the Slippery Slope.  American Journal of Psychotherapy. 46:4, pp 544-555.

Veatch, RM. (1989) Medical Ethics. Jones and Bartlett Publishers, p. 7.

Wohlberg, JW. (1997) Sexual Abuse in the Therapeutic Setting: What Do Victims Really Want? Psychoanalytic Inquiry, 17:3, pp 329-348.

© Copyright 2004 Kathleen S. Lundgren, Wanda S. Needleman, Janet W. Wohlberg 

For more information on the positions of this paper, see: >http://www.ncbi.nlm.nih.gov/pmc/articles/PMC479298/pdf/jmedeth00007-0048.pdf<