It demands a delicate balance between the head and the heart.
Is it appropriate for physicians to treat members of our nuclear and extended families? For many decades, the debate on this issue has raged in the literature at meetings of every specialty, and at ethics symposia. Opinions run strong on both sides of the conversation.
In the May 2012 AMA Journal of Ethics, the AMA Council on Ethical and Judicial Affairs stated a view with which we are all familiar: “Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgement, thereby interfering with the care being delivered.” The council goes on to say that it is acceptable to treat family members acutely in an emergency where other medical personnel are not available.
So what do physicians do in the real world?
NATURALLY, IT HAPPENS
I am sure most of us have been asked to examine a medication for a relative, prescribe one or both. Indeed, I have examined my family members’ charts and documented conditions such as seasonal allergies and bacterial conjunctivitis. As a cornea and external disease specialist, I am confident in my diagnosis of, and treatment for, these conditions.
Further, having been an FDA investigator for LASIK in the 1990s and performed tens of thousands of these procedures, it was natural to perform LASIK on my sister. I know many physicians would not agree, but my experience in performing these procedures provided both of us with the comfort and confidence to proceed, with no shortcuts in pre- and postoperative counseling or thorough discussion of the risks of surgery.
Many years before that, my father, a plastic surgeon, sewed a facial laceration I sustained while playing sports. I remember feeling that there was no one who I wanted to perform that procedure more than him.
WHERE DO WE DRAW THE LINE?
So, what is acceptable treatment for our family members? Are you comfortable diagnosing and treating glaucoma, for example? Is it okay to monitor and treat diabetic retinopathy or AMD if you are skilled at performing these services for others? Are you asked to care for other doctors and their family members?
Some colleagues who I have queried about this sensitive topic argue that it is different caring for eye conditions than, say, treating a relative for a myocardial infarction or performing more involved abdominal, genito-urinary, cardio-thoracic or orthopedic surgeries.
WHAT DOES THE LITERATURE SAY?
In an article published by the Hastings Bioethics Forum in May 2018, author Mary Click describes the decision to be involved in our family members’ health care as “sticky and human.” Several doctors involved stated that, when faced with difficult medical situations on behalf of family members, they were “unable to be objective, tolerate a loved one’s pain or keep medical decisions separate from family dynamics.” At the same time, each of the physicians were in possession of knowledge, opinions and connections that could help their loved one facing a health crisis and withholding these resources “may have seemed impossible.”
Lastly, the paper “When physicians treat members of their own families,” published in the New England Journal of Medicine in 1991 found that, on one hand, physician-family members are often more sensitive to health issues, are able to explain the disease process and treatment options very well and may find that “attending to ill family members is a natural and rewarding opportunity.” On the other hand, the authors noted that part of the ethical dilemma raised comes from observations that charts and examinations are sometimes incomplete and the care less comprehensive.
As for reimbursement, since 1989, Medicare has not paid for medical services rendered to immediate relatives, and Blue Cross, with even stricter definitions of immediate family, has not paid for these charges since 1976.
This is a most delicate and important debate and is nearly always on the agenda of ethics symposia. Where is the line drawn? Certainly, the families of patients are engaged in making end-of-life decisions on behalf of their parents, siblings and children, despite their being equipped with far less medical knowledge. Code status, informed consent and denial of care deemed necessary by doctors are all forms of medical care and decision-making, and society accepts this involvement as a matter of course.
Eye-related care is often considered a “carve-out” of medical services. As such, there may be a broader degree of acceptance for the treatment of certain conditions, such as contact lens fitting or treatment of ocular allergy or conjunctivitis.
That said, how about following your algorithm for open-angle glaucoma? Uveitis? ALT/SLT/PRK/LASIK? Cataract surgery? Similar to the medicines we prescribe off label, there is no definitive law regarding the delivery of medical care for immediate family. It remains an individual decision and perhaps defines an even higher level of the doctor-patient relationship. OM