Giving medical care to a relative may appear a logical course of action, but it can put both doctor and patient in a precarious position, as Dr Gerard Panting explains
What should you do when faced with a close relative who needs medical care? Prescribe yourself? Refuse and insist that your son/daughter/husband or wife goes to his or her GP just like anyone else? But what if it is Sunday morning and you are about to catch the ferry to Cherbourg to begin your summer holiday?
There is no law against doctors treating family members, and here ‘family’ probably means first and second degree relatives rather than long lost cousins twice removed by marriage. Having said that, the GMC appears to discourage the concept on ethical grounds.
First, there is the question of objectivity and the danger of emotional attachment colouring assessment and treatment.
Second, there is the difficulty of ensuring thorough history taking and examination when some subjects or forms of examination might be too embarrassing to broach, resulting in systematic assessment being replaced by guesswork.
Third, there is concern that when things go wrong, problems may be compounded by inappropriate remedial treatment.
Fourth, again when things go wrong, the patient is likely to be inhibited from seeking redress, including financial compensation.
Last, and very rarely, there is the issue of ulterior motive, with the patient not being treated in accordance with his or her best interests but to serve some personal purpose for the doctor.
It would be ridiculous to suggest that doctors should never treat family members. Non-medical parents are encouraged to provide symptomatic relief for their children’s illnesses with over the counter medication.
The difference for doctors is that they also have access to prescription only medicines, but the need for treatment may be just as straightforward and obvious as a parent’s recognition that the child’s temperature should be reduced by giving paracetamol syrup.
So when it comes to catching that ferry, treating your five year old’s acute otitis media with antibiotics and analgesia cannot warrant serious criticism.
Equally, a relative whose supply of anti-hypertensives or thyroxine will not see them through the holiday might reasonably ask for a repeat prescription. After all, failure to provide it may pose significant risk and the GMC itself says "In an emergency, wherever it may arise, you must offer anyone at risk the assistance you could reasonably be expected to provide1
Away from these urgent situations, however, the arguments against treating family members gather more force.
Administering proper medical care
In Good Medical Practice, the GMC says that good clinical care must include an adequate assessment of the patient’s condition based on the history and symptoms and, if necessary, an appropriate examination, providing or arranging treatment, taking suitable and prompt action, and referring the patient to another practitioner when indicated. Should the doctor be in any way prevented from meeting any of these requirements, he or she is on thin ice.
There is also the temptation, for the sake of expediency, to do things yourself that would normally be referred on to somebody else. Straying beyond the limits of your expertise is another way of being drawn into the danger zone.
These issues are particularly relevant when it comes to the treatment of psychological and other chronic conditions, particularly where patients may become dependent on the medication.
And then what does happen if something goes wrong? Will embarrassment over what has happened prevent the doctor from seeking help from appropriate specialists? If this is the case, there is the chance that things will go from bad to worse, with the patient suffering in the vicious circle that ensues.
There may well be circumstances in which a family member insists that he or she will see no-one else. This is a real dilemma for the doctor, who will doubtless try to persuade the patient to see sense. However, if ultimately the patient refuses to go elsewhere, the doctor cannot be expected to stand by idly while the patient deteriorates.
Such situations require delicate handling, dialogue and a programme of persuasion, rather than resignation that the patient just will not see sense.
Dangers for patients
If a patient suffers harm from a shortfall in care, perhaps resulting in loss of earnings or permanent disability, the remedy is to sue for damages. Litigation is a difficult and drawn out process at the best of times but making a claim against someone in the family must be much more difficult.
That, combined with fears of getting the doctor into trouble will inevitably inhibit the patient from seeking appropriate redress.
Ulterior motives are not completely unknown among doctors, whether the intention is to relieve behaviour or symptoms more irritating to the doctor than the patient, or there is a more sinister motive.
Doctors who place their own interests, whether financial or personal, above those of their patients clearly act in defiance of the standard required by the GMC which says "You must not give or recommend to patients any investigation or treatment which you know is not in their best interests, nor withhold appropriate treatments or referral”.1
Avoiding the risks
So as a matter of common sense, most, if not all, doctors are going to provide simple advice and treatment for family members for acute conditions where it is more convenient to provide it than for the patient to wait for hours in an A&E department or a doctor’s waiting room.
However, when it comes to more serious conditions requiring objective appraisal, doctors should be wary of providing advice and treatment when it is almost as convenient for the patient to go to a colleague.
Similarly, doctors who prescribe controlled drugs,drugs of habituation or perhaps drugs, which, for the patient’s condition, have no sound evidence base, are steering towards trouble.
Should that trouble come, it is likely to be in the form of a letter from the GMC which will require detailed justification for the doctor’s actions and an explanation as to why referral was not made to a suitably qualified colleague.
- General Medical Council: Good Medical Practice. London: GMC, May 2001.