From Coercion to Christmas

The recent wave of stories of sexual abuse and harassment led my residents (I teach family medicine residents) and me to a discussion of sexual ethical violations in medicine. The annals of disciplinary actions by state medical boards are filled with penalties inflicted upon physicians who have entered into sexual relationships with patients.

Why is it that in the patient-physician relationship, sexual intimacy between two (often) consenting adults is proscribed, and has been since Hippocrates prohibited it in his oath? Why, even in our sexually permissive age in which anything goes, is this still taboo?

The issue with physicians and patients — as with most of the accusations making headlines recently — is power. The patient-physician relationship is radically asymmetric with regards to power. The patient is vulnerable; the physician is not. The patient reveals dark secrets, and uncovers his or her body for examination; the physician does not. One person in the room is exposed, figuratively, and literally, and it ain’t the doctor.

It is this asymmetry, this difference in power, that makes it so difficult for an intimate relationship to be truly consenting; there is a very real danger that the less-powerful party will act from some sense of coercion, even if the coercion is unrecognized and unacknowledged. When a relationship as intimate and personal as a sexual relationship is coerced, even subtly, the potential for harm to the weaker partner is so great that the ancients, in their wisdom, forbade it, and we moderns have seen fit to respect that prohibition.

Of course it is not just patient-physician relationships that are asymmetric and thus liable to abuse. Whenever one person exploits their position of superior power over another the potential for abuse exists, such as when a person with great political power personally attacks those in positions of less power on social media. We call such abuse of power “bullying.” We rightly condemn such abuses.

This got me to thinking about the most asymmetric relationship possible: the relationship between God and people, the Creator and the created. While there is no sense in which God could be said to abuse his power, he seems remarkably restrained in his exercise thereof. We read of times when he shows up in dazzling displays — think of the children of Israel leaving Egypt, or God speaking to Job out of the whirlwind — but more often than not he is veiled: a still small voice, a dream, a soft but persistent voice in the night that keeps calling our name.

And when God gives us the clearest revelation of who he is, he eschews any semblance of powerful exhibition, and comes as a baby. When he grow up and displays his power, it is veiled in love: he heals, he saves a wedding celebration from disgrace, but often with admonition, “Don’t tell anyone.” Even his greatest display of power — his Resurrection — was carried out in such a way that many of those nearest to him had a hard time understanding or believing it.

God is powerful, no doubt. But he rarely uses his power to overwhelm or coerce us. He seems to prefer self-giving love as his means of persuasion. We are told that someday he will come in a full demonstration of his power and glory. But for now, as we celebrate at Christmas, he comes to us as a baby. He comes to be with us, as one of us, so that he can lead us from where we are to God. Or, as an old Christian named Athanasius said, “He became as we are, that he might make us what he is.”

I’m on call for our obstetrical service this holiday. I’m going to try to let each baby I see be a reminder of how God deals with us: power that clothes itself in self-giving love.

Thank you for treating me like a person

I went down with the resident to the emergency department to hear the patient’s story (aka “Take a history”) and perform a physical exam as part of the patient’s admission to the hospital. As we were getting ready to leave, the patient said, “Thank you for treating me like a person.”

What does it say about our medical system when “treating someone like a person” is considered an object of special gratitude, peculiar enough to be singled out and mentioned?

It’s not primarily about the guns

A recent article in Dignitas and a recent post to this blog discuss gun violence as a public health issue. I don’t know if the broad category of gun violence properly falls under the heading of public health, but one aspect of it certainly does: accidental firearm injuries in the pediatric population. It is difficult to obtain reliable statistics to say how prevalent this problem is, since Congress has blocked the CDC from firearms-related research since the early 1990s; I have read estimates that put it anywhere between the ninth- and sixth-leading cause of accidental deaths among children aged 1-14.

As a family doctor, I see pediatric patients for well-child exams. At these exams I provide “preventive guidance.” I ask patients and their parents about various age-apropriate things that have been shown to affect the health and life of children, and provide guidance where indicated. I recommend things like smoke detectors, infant/booster seats or seat belts, bicycle helmets, and fences around swimming pools. I recommend against smoking, drug use, and keeping bleach and aspirin where young children can reach them. I make sure parents have the phone number for the poison control center. And if there are guns in the household, I recommend they store them in a way that their young children cannot accidentally access them.

In 2011 Florida passed the Firearms Owners’ Privacy Act. This act provides that a doctor “should refrain from” asking a patient about firearms, unless he believes “in good faith” that the “information is relevant to the patient’s medical care or safety, or the safety of others.” Penalties for the criminals who don’t “refrain from” asking about firearms include fines and the loss of one’s medical license. The district court wisely blocked the law in 2012. However, the state of Florida appealed, and this past July the 11th Circuit Court of Appeals reversed the lower court’s decision.

This situation falls into the arena of bioethics, not because it has anything to do with guns; not because it has anything to do with pitting one Constitutional right against another; but because it is an unreasonable and unwarranted intrusion into the physician-patient relationship. As the appeals court wrote in its opinion, the government does regulate the practice of medicine. But the government proscribing what a physician can talk about with her patients? This is a far different thing than the government proscribing, say, the sharing of private patient information or participating in kickback schemes.

At the heart of the profession of medicine is the patient-physician relationship. This relationship is built on the foundation of one person acting altruistically in the interests of another person. The relationship is perverted when it is forced to serve the political agenda of an outside interest group. The precedent set by this law is corrosive to the fiduciary nature of the relationship, and should be overturned — and if not overturned, then ignored by all physicians who value the profession.