Amin A. Muhammad Gadit  ( Memorial University of Newfoundland, Canada. )

Doctors by virtue of their profession are the main front line care givers. To be good to their patients, maintaining all the ethical boundaries and follow their duty to care are the important landmarks in their personality. Human nature leads to friendly behaviour, emotional attachment and intimate relationships. Such relationships or attachments between a doctor and patients often lead to complications, especially if the genders are opposite. There are a number of guidelines, developed for the medical profession by the global regulatory authorities, which embed ethical concerns and dilemmas in the event of personal intimacy in doctor-patient relationship. According to Bernstein,¹ ethical concern arises because of potential conflict of interest and loss of objectivity on the part of physicians leading to a compromise in patient care. Sexual relationships are never permitted and if emotional involvement develops, it should be kept a secret or the patient be referred to some other physician. Stephen Post² quotes a research stating that "physicians are shown at their worst, leading to the conclusion that the patients must be protected from their doctors." Rourke and Rourke³ describe a number of challenges that are met with in this relationship. Omissions by patients can be in the form of not sharing correct information with doctors and by doctors not inquiring about relevant psychological or sexual problems. Confidentiality breaches especially in rural communities is also a major problem, assumptions about patients and counter transference, loss of objectivity especially by heightened emotional involvement and blurred boundaries are few other major challenges. In the local context, it has been observed that a number of doctors get involved with patients in terms of friendship. Reports on opposite gender friendships have led to serious complications and scandals that have brought a bad name to the profession and raised serious ethical concerns. It has been rightly said that friendly relationship can enhance rapport and promote empathy that helps in the medical management of patients. The patients in majority of cases are psychologically vulnerable and may get emotionally involved with their doctors. The doctors on other hand should have a balanced personality and be trained in their medical education years on the aspects of dealing with the patients professionally. Unfortunately, a number of doctors are found to be emotionally fragile and yield to emotional bonding without considering the ethical barriers. There are a number of cues from the patients that the doctors should be aware of, for example: seeking frequent appointments, making repeated telephone contacts, sending e-mails, providing gifts, inviting in social activities, calling the doctor by first name etc. Likewise, the patient should be aware of the cues generated by doctor, for example: prolonging consultation times, offering repeated appointments, contacting on phone, discussing personal life, showing excessive intimacy, extending social invitations and violating personal space limitations. Sometimes, there is a hidden agenda on either part, like, aim to get desired prescriptions for example sedatives that have abuse potential, concessions in fee, out of hours contact and getting other privileges. Coming back to doctors, the most vulnerable professionals are the psychiatrists and obstetrician-gynaecologists.⁴
Empathy is good for better doctor-patient communication but friendly relationship can lead to ethical complications and hence should be avoided. Specific precautions should be observed in even addressing the patient as the \'terms of endearment\' must be avoided, exchange of gifts is another grey area that is widely debated.⁵ It is important to avoid to meet the patient for reasons other than a properly arranged clinical consultation appointment. In the event of dealing with an emotionally fragile and vulnerable patient that can cause feeling of discomfort, the concerned doctor can refer the patient to another colleague. Lengthy closed door consultation should be avoided as much as possible especially while dealing with patients from opposite gender. At times, such consultations are unavoidable in psychiatric review, therefore, a family member or a nurse should be present. It is important that the Pakistan Medical and Dental Council (PMDC) should devise guidelines for the doctors. The American Psychiatric Association offers some guidelines: If it becomes imperative to terminate the treatment responsibility, a number of steps should be taken: a discussion session with the patient focusing termination, this discussion should include reasons, termination date, availability for emergencies only until date of termination, willingness to provide names of other appropriate therapists and arranging referrals. It is important to allow the patient reasonable time to find another therapist, provide the patient\'s records to the new therapist upon authorization by the patient, a letter for necessity of ongoing treatment and a proper termination letter thus ending the relationship in the most ethical way.⁶
Availability of specific guidelines can help maintaining smooth and ethical doctor-patient relationship. In our already fragile health care system, would it not prevent a number of adverse social issues resulting from deviant relationship between the care giver and the recipient?

1.Bernstein M. What to do when patients become friends-Embrace it or end it? 2010. (On line) (Cited 2010 May 26). Available from URL: http://www.parkhurstexchange.com/clinical-reviews/may10/patient-friendships.
2.Post S. Beyond adversity: physician and patient as friends? J Med Humanit 1994; 15: 23-9.
3.Rourke LL, Rourke JT. Close friends as patients in rural practice. Can Fam Physician 1998; 44: 1208-10.
4.No author listed. Appropriate boundaries in the paediatrician-family-patient relationship. American Academy of Paediatrics. Committee on Bioethics. Paediatrics 1999; 104: 334-6.
5.Abbasi YI, Gadit AM. Accepting gifts from patients: how ethical can this be in the local context? J Pak Med Assoc 2008; 58: 281-2.
6.Simon RI, Shuman DW. The Doctor-Patient Relationship. Focus. 2007; American Psychiatric Association. (Online) (Cited 2010 June 11). Available from URL: http://focus.psychiatryonline.org/cgi/content/full/5/4/423/T1.