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Nor is love in the supermarket based upon a fiduciary relationship (see later discussion).In addition, ‘love transference' can be extremely capricious, often hiding a destructive hate transference that frighteningly erupts and engulfs the therapist and patient.Many boundaries exist in the doctor–patient relationship.These include boundaries of role, time, place and space, money, gifts and services, clothing, language and physical contact.First, the concepts of boundaries and transference are discussed and a profile of the medical practitioner at risk of offending is drawn.Secondly, three aspects of the doctor–patient relationship are explored: the general characteristics which promote health care; the importance of trust and the fiduciary relationship; and the role of power and authority in the relationship.
On the basis of this evidence, it is argued that the circumstances in which such relationships are ethically permissible are extremely limited and that official ‘sanctioning' of these relationships should be very much the exception, not the rule.
Sexual misconduct usually commences with violations of more minor boundaries:“The road to therapist–patient sex is paved with progressive boundary violations.
Except when a patient is raped, the therapist who eventually sexually abuses a patient follows a remarkably predictable ‘natural history' of sexual misconduct.” Not all stages will take place in any one relationship, but the general stages include: gradual erosion of therapist neutrality; socialization of therapy; the patient is treated as ‘special'; doctor's self-disclosures begin; physical contact begins (e.g.
However, the crossing of boundaries does not necessarily mean that an unethical act occurred: after all, the crossing or erosion of boundaries is a normal part of the evolution of intimate relationships between human beings. Clues as to what these other factors should be can be gleaned from examining the profiles of offending doctors.
Nor do all boundary transgressions between doctor and patient ultimately lead to sexual misconduct. A key factor in the identification of doctors at risk of violating boundaries is the enhanced vulnerability of a doctor to the transference–counter-transference dyad which occurs in varying degrees in every doctor–patient relationship.