Legal Commentary

Article 4.2.5.1 of the Singapore Medical Council Ethical Code and Ethical Guidelines (ECEG) provides that “a doctor must not have a sexual relationship with a patient. This is to preserve the absolute confidence and trust of a doctor-patient relationship”. The prohibition extends to any “improper associations with immediate members of the patient’s family” that the doctor may enter into as a result of the professional relationship with the patient, the rationale being that such a relationship “would disrupt the patient’s family life and damage the relationship of trust between the doctor and his family”.

Few would argue with the idea that doctors must maintain boundaries within their relationship with their patients. Instinctively we would view a doctor who enters into a sexual or romantic relationship with a patient to be behaving unprofessionally and inappropriately. The doctor stands in a unique position of trust with his patient. His role as medical doctor allows him private access to the patient and the patient’s confidential information. As for the patient, she is dependent on the doctor for advice and medical care. The relationship dynamics are such that the two do not stand on an equal footing. While the ECEG refers specifically to the prohibition against sexual relationships and improper associations with members of the patient’s immediate family, it also tells us that the core concern lies in the need to preserve and uphold the relationship of trust, and not doing anything to harm the patient, such as disrupting the patient’s family life. This then raises the very question posed by the case described above, namely, whether a doctor can be said to have behaved inappropriately with a patient if he were to establish or encourage an emotional relationship with that patient that does not involve sexual relations.

It would be unrealistic to think that patients never form an emotional attachment to their doctors, and that when it happens it is always to be considered a bad thing. Many patients consult their trusted family physician over the course of their lives, and treat their doctors like old friends or trusted confidants. Doctors who are viewed as more than just a doctor by the patient, are often in a position to positively influence the patient by encouraging good, healthy practices that promote the patient’s well-being. This is because often the patient may be more committed to complying with the doctors’ advice when he or she shares a good relationship with his or her doctor. When the end effect is beneficial for the patient, we are less likely to question the good intentions of the doctors or impute any form of ulterior motive or bad faith on their part. Since we are told that the relationship between Ms. J and Dr. D ended in misunderstanding and humiliation for Ms. J, and this in turn appears to have had a negative impact on her medical condition, it would be easy to immediately conclude without further reflection that Dr. D must have behaved in an inappropriate manner. But it is necessary to go further to determine if the doctor has acted inappropriately based on his actions and intentions, and not purely on what we know about how the relationship ended, or the effect the relationship actually had on the patient. We must examine how it was that Ms. J ended up developing romantic feelings for Dr. D in the first place, and whether Dr. D’s intentions or conduct had a direct impact on creating that situation.

There are several factors here that raise red flags. For a start, Ms. J had been seeking treatment from Dr. D for her BPD. As a psychiatrist, Dr. D would have known that patients with BPD may have unstable emotions and difficulty with social relationships. We expect him to recognise the need to exercise extra care in maintaining boundaries and the importance of ensuring that the relationship continues to remain a strictly professional one. Even if Dr. D were to say that he genuinely did not read as much into their interactions with each other outside of the consultation room as...