When your mother wants a script:
The ethics of treating family members

CASE


As with any field, knowledge of medicine gives health care providers the ability to answer questions, explain procedures, and calm fears. Within a patient-provider relationship, sharing this knowledge is expected and required. Within their own family, however, how much should clinicians share? Research has shown that health care providers do give medical advice to relatives, with La Puma noting that 99% of 465 physicians surveyed had requests from family members for medical advice, diagnosis, and treatment.¹ Physicians and PAs, when taught medical ethics, are advised not to treat family members. Yet soon after completing school, PAs may find themselves asked to do just that. There is no research on PAs, but 83% of surveyed physicians reported prescribing medications to family, 80% had diagnosed illnesses, 72% had performed physical examinations, 15% had acted as a family member's primary doctor, and 9% had performed surgery on a family member.¹ Those same physicians responded to requests in increasing proportion to their age and the number of years they had been in practice.¹ 


While some providers feel that strict adherence to ethical guidelines is a necessity, these data show that others do not feel so strongly. One surveyed physician wrote, "What good is all that training if you can't help your family?"² To answer this question for themselves, PAs can 
benefit from reflecting on medical ethics, their own familial situation, and their role within the health care system to ensure the best care for their loved ones.


A HYPOTHETICAL CASE


A 20-year-old woman with no prior medical history approaches her brother, a PA, at a party with complaints of lower leg pain that has been bothering her since she moved into her fourth-floor college dorm room two days earlier. She asks him to prescribe muscle relaxants for her strained muscle. He says he is not comfortable prescribing her medicine as he works in ENT. He suggests that she make an appointment at the college health center the next day. She insists that he call in the prescription, stating that she has confidence in his training and reassuring him that she has used the medication in the past with no adverse effects. In the end, he tells her he'll call in a prescription if she will make an appointment to be evaluated the next day. That night, the woman develops shortness of breath and tachycardia, symptoms suggesting a pulmonary embolism.


ETHICAL DEBATE


The AMA Council on Ethical and Judicial Affairs states, "Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member of the physician is the patient."³ Failure to adhere to ethical standards puts health care providers' occupations and the lives of family members in jeopardy.⁴ This can be demonstrated, for example, in the case of Kalika Bamberski, who was allegedly killed by her stepfather when he injected her with a substance said to induce a tan.⁵ When donning the white coat, PAs take a vow to hold themselves to a higher standard of bioethical principles, which comprise principles not only of beneficence but also of nonmaleficence, including the responsibility to avoid harming the patient by knowing one's own limitations. One of those limiting circumstances is the ability to objectively make decisions without wavering under outside influences. Pressure from family could, even at an unconscious level, influence decision making, resulting in unintended consequences both to the family member and the provider. Perhaps most troublesome, a precedent could be established. 


The other side of the debate explores why family members ask for medical help and health care providers' motivations for extending treatment. Requests from relatives may involve asking for factual information, referral recommendations, interpretation of laboratory results, medical judgment in specific medical situations, and medical opinions on the 
appropriateness of care.⁶ Requests occur most often in circumstances involving minor illnesses, end-of-life care, and navigating the bewildering medical system.^6,7 Most requests come from providers' children.¹ A PA can provide comprehensive commitment to a relative's well-being through specific attention to details in the overall care plan, an asset that may have been underestimated when ethical guidelines were established.² 


The reasons motivating providers to treat family are typically compelling, and usually no problems occur. However, things can go wrong. Perhaps it is the informal manner in which family members request medical care that results in compromised care. Medical histories may be assumed or incomplete, as family members may withhold information (for example, the woman in the hypothetical case did not mention she took oral contraceptives), or the provider may feel uncomfortable asking personal questions. Providers may abbreviate the physical examination or attempt to provide care that goes beyond their area of expertise. Finally, emotional involvement could get in the way of appropriate evaluation (for instance, a husband may deny his wife's symptoms of colon cancer).⁸


PAs may intend to keep their roles as family member and health care provider separate but still involve themselves because of a desire to appear knowledgeable or frustration with the treatment being given by other providers.² Nevertheless, when health care providers blur the boundary between family member and provider, they often feel conflicted. One physician stated, "I think there's this dangerous feeling that we all have of getting in there and doing something."² 


CONSIDERATIONS


While the greatest number of physicians who responded to family requests were ones who had many years of medical experience, PAs at any stage in their career would benefit from reflecting on the following questions:⁹


Medical ethics: Is what I am about to do consistent with my medical training? Will the "office" I hold be compromised? Will I be fulfilling my role in totality if I treat or prescribe? Can I be removed enough from the patient to provide objective care, not erring in paternalism (making decisions with little patient consent) or radical individualism (allowing the patient to dictate what is prescribed)?


Familial role: Who are family members? PAs may be more emotionally connected to those who are not relatives than to those who are.¹ Am I willing to probe into intimate areas or be the bearer of bad news? Would taking care of this family member bring about or increase existing familial conflict? Will the relative actually comply with my treatment or listen better to another provider? The family member may doubt your ability and not follow through with treatment. Some be­lieve that patients are more apt to follow advice that is paid for than care given free.⁹ Is my emotional involvement going to inhibit the patient's full autonomy in medical decision making? Vulnerable family members may be reluctant to exercise full autonomy and defer to their familial health care provider.⁷ What would be the consequences if I refuse treatment?² 


Health care role: Am I trained to treat this? This is particularly important as the PA profession leans more towards specialization. Will my care be too much, too little, or inappropriate? One must be aware of the possibility of over-testing and under-testing.⁹


If PAs choose to respond to a family member's request, they should adhere to some guidelines. First, PAs should establish for both themselves and the patient that the relationship between them is different from the relationship that would exist between the patient and a nonrelative provider. This may include stating clear expectations, remaining professional even in informal settings, and respecting autonomy and confidentiality.⁶ Documenting the encounters in medical records in a secure and confidential setting is essential. These charts should be accessible only at the appointment or chart review, ensuring protection of the practice, family members, and the provider.¹⁰ PAs need to keep in mind that patients will more likely adhere to medical advice if a fee has been charged. Finally, if the situation requires a physical examination, it should take place in a formal office setting.⁶


CONCLUSION


Ethical principles say that health care providers should not treat family members, but many do so anyway. Thus PAs should review and reflect on these ethical principles and related considerations when faced with difficult decisions connected to the care of family members.² Such reflection will help to maintain the PA's professional standing and enhance health care for those they love. JAAPA

Helene Hill practices in emergency medicine in Buffalo, New York. Matthew Hill (her husband) is finishing his PhD in ethics at Durham University in Durham, England. The authors have indicated no relationships to disclose relating to the content of this article.

REFERENCES


1. La Puma J, Stocking C. When physicians treat members of their own families. N Engl J Med. 1991;325:1290-1294.


2. Chen FM. Role conflicts of physicians and their family members: rules but no rulebook. West J Med. 2001;175:236-239.


3. AMA Council on Ethical and Judicial Affairs. Code of Medical Ethics, Opinion 8.19. Chicago, IL: American Medical Association Press; 2010.


4. Nicholls M. Doctors should not treat family. BBC News. October 21, 2009. http://www.hc2d.co.uk/content.php?contentId=12965. Accessed January 5, 2011. 


5. Sommers A. German stepdad suspected in Kalinka Bamberski's death. New York Daily News. October 21, 2009. http://www.nydailynews.com/news/world/2009/10/21/2009-10-21_stepdad_suspected_in_death_of_girl_is_kidnapped_left_tied_up_near_courthouse_by_.html. Accessed January 5, 2011. 


6. Eastwood G. When relatives and friends ask physicians for medical advice: ethical, legal, and practical considerations. 
J Gen Intern Med. 2009;24(12):1333-1335.


7. Issa AM. Taking off the white coat: can family members who are physicians be good surrogate decision-makers?" J Am Geriatr Soc. 2002;50:946-948.


8. Carroll RJ, Tulsky J, Shuchman M, Snyder L. Should doctors treat their relatives? Ethics case study #21. ACP-ASIM Observer. January 1999. http://www.acpinternist.org/archives/1999/01/relative.htm. Accessed January 5, 2011.


9. La Puma J, Priest R. Is there a doctor in the house? JAMA. 1992;267(13):1810-1812.


10. Apgar C. HIPPAA Q&A: physicians treating family members. HIPPAA Weekly Advisor. March 29, 2010. http://www.
hcmarketplace.com/prod-866/HIPAA-Weekly-Advisor.html. Accessed January 5, 2011.