Many professions build in stringent boundaries separating appropriate from inappropriate relations between practitioners and clients. The boundary protects against abuse by the professional and inappropriate demands by the client. Remember the clinician’s guide for psychotherapists. In addition to the practices mentioned in chapter 1, it warns sternly against providing patients with falsified diagnoses that qualify the patient for reimbursement or disability payments, and against testifying for a patient in a legal dispute. Besides being illegal and unethical, the guide warns, such practices go beyond “the clinician-patient relationship to become a ‘special favor’ ” (Reid 1999: 87). Clinicians are similarly cautioned not to make disability assessments for patients applying for insurance or government benefits. Furthermore, and even more strongly, the guide stigmatizes the disclosure of confidential patient information except in cases of lawful subpoenas, or patient-authorized release to payers, such as insurers.
Clinician and patient relations, moreover, should never slip into financial adviser-investor exchanges:
For example, if a patient who is a company executive divulges some business matter during therapy that might affect the price of a stock, buying or selling the stock could be considered a breach of privilege, an action in other than the patient’s interest, or insider trading. The same applies to help or “tips” you might give the patient.. .. Do not suggest, recommend, or even inform the patient concerning such things as investments,
and be cautious about direct advice on such topics as employment and relationships. There is a difference between eliciting thoughts and feelings to encourage good decision making and inappropriately influencing those decisions. (Reid 1999: 89-90)
The guide also counsels against seeing patients after hours or making the clinician’s home telephone available to them. Psychotherapists center their professional expertise on a certain kind of intimacy. Yet they also impose a sharply bounded definition of proper and improper intimate transactions between therapist and patient.
Not only psychotherapists, but many other medical specialists, run the risk of damaging intimacy. They, too, commonly set up ethical barriers against the possibility that intimate relations will compromise the effectiveness of their treatment—and the reputation of their profession. A widely used manual on medical interviewing, written for students, presents this cautionary tale:
When I was an intern, I remember spending a great deal of time with a young woman diabetic patient who had taken an insulin overdose after an argument with her boyfriend. I offered her empathy and understanding, talked to her about the importance of getting counseling, and explored ways that she could improve her social situation and respond more appropriately to stress. The Sunday after her discharge, she paged me and asked if she could see me in the hospital lobby. Though I was having a busy on-call day, I met with her, listened to her latest problems with her boyfriend, and held her hand as she cried. She asked if we could have lunch the next day. I agreed.
I realized that meeting her for lunch was inappropriate, but had felt that doctors needed to be available for their patients and should be able to “go the extra mile” to help them. I had been flattered that she found me so helpful and enjoyed feeling competent in my counseling skills, at a time when my feelings of competence were being otherwise challenged by the sick and dying patients on my service. I probably was also attracted to her, and enjoyed the intimacy of our conversations. I realized, though, that responding to my own needs was undermining my ability to help her. At lunch the next day, I told her of my discomfort and discussed the need for setting appropriate professional boundaries if I were to continue caring for her in the outpatient clinic. (Cole and Bird 2000: 242-43)
“Appropriate professional boundaries” prevent the corruption of medical treatment by the wrong kind of personal intimacy. The professionals differentiate sharply between interpersonal transactions that are appropriate or inappropriate for different sorts of intimate relations.