I recently met Richard Martinez, MD, of the Program in Health Care Ethics, Humanities and Law at the University of Colorado Health Sciences Center. Rick is a compassionate man who has expertise in forensic psychiatry and ethics. He has written a paper that I believe can provide a good model for looking at boundary crossings in our profession.1 The basic idea is that the modern model is a "slippery slope" because it implies that once the boundary is crossed, the situation becomes unmanageable, leading to a serious transgression. Thus it has been conventionally thought that the boundary should never be crossed. This traditional model fails to distinguish between boundary crossings that might be beneficial to the client and those that are potentially harmful.
Martinez remarks that prior authors have noted that ethical transgressions usually relate to the following: roles, money, time, space, treatment location, gifts, services, language, clothing, self-disclosure and physical contact.2 This gives us a clear set of clues to assist us in detecting where boundary problems are often to be found, helping us to be alert to them before they become problematic.
Martinez promotes the "graded-risk" model as an alternative to the traditional slippery-slope idea (see Table). In Martinez' graded-risk model, there are circumstances where a boundary crossing might be necessary to benefit the client, and that failure to do so might be considered malpractice. I'd like to clarify a bit more about some of these factors. Each can be thought of as a continuum.
Potential Harm to the Patient: This seems like something which would be easy to judge. But we must be careful in evaluating this question. As an example, if we choose to cross a boundary, we might create a situation in which the patient might choose to terminate treatment due to their being uncomfortable with the situation.
Potential Benefit to the Patient: Here, we might think of a scenario in which a client asks if we have ever had acupuncture. We might choose to share our own experience in order to bond with the patient, help them trust us or help them better understand the procedure.
Presence or Absence of Coercive and Exploitative Elements: Obviously this refers to things like conflict of interest. In our profession, we usually sell herbs, supplements and home health supplies to patients. Of course this is because the materials we recommend are not readily available. However, we might be seen as potentially exploiting a patient by doing this. In conventional medical circles, selling things to patients has traditionally been prohibited, along with owning pharmacies at which patients purchase drugs. I think this is an area in which we must be cautious.
Professional Intentions and Motives: Here we must examine a given scenario to assess the presence or absence of the normal intentions and motives that would be expected of a professional in health care. If the activity completely lacks evidence of such motives, clearly there is a serious problem.
Aspiration to Professional Ideals: In this domain, the boundary crossing is evaluated according to whether it appears that the professional demonstrates intentions that would be expected of a health care provider. Therefore a provider might choose to cross a boundary, even though one could anticipate criticism, because one truly believed that it was the best thing for the patient.
|Type of Boundary Crossing||Risk of Harm to Pt. & Pt.-Prof. Relationship||Coercive & Exploitative Elements||Potential Benefit to Pt. & Pt.-Prof. Relationship||Professional Intentions & Motives||Professional Ideals||Recommendations|
|I||High||Present||None-Low||Professional self-interests over patient interests||Absent||Discouraged and prohibited|
|II||High||Ambiguous||Low||Professional self-interests blur patient interests||Absent or minimum||Highly discouraged; rarely justified|
|III||Low-Middle||Absent||Middle-High||Patient interests over professional self-interests||Present, discernment and judgment important||Encouraged as benefit increases; justified at times, above call of duty|
|IV||None-Low||Absent||Middle-High||Patient interests over professional self-interests||Present; ideal mode of care||Strongly encouraged; justified; obligated as benefit increases|
I believe that Martinez would say that any situation that qualifies as a type IV boundary crossing in all squares across would be acceptable, if not an obligation. He might even say that type III crossings can be acceptable, if they truly meet criteria in all squares across. Obviously, type II and I crossings are dangerous to patients, if not downright unethical. These tend to be easier to detect in our practices. Those events that fall in the type III category are a bit tricky. This model might be very helpful in our field, as we continue to develop our ethical standards.
Here are some example scenarios that are typical of the potentially complicated situations that acupuncturists may encounter. See if you can place the situation in one of the four categories that Martinez has suggested.
Roles: You are working on a client who is an avid gardener. Knowing this, you ask for advice about a tricky problem in your garden. The patient enthusiastically gives suggestions for your problem.
Money: You realize that a patient is having financial hardship. At the time they are checking out, you discount their visit without discussion or informing them ahead of time.
Time: A patient comes for a seemingly minor problem but as you get into it, you find that things are much more complicated than you originally expected. You end up spending twice the normal amount of time with them.
Space: Knowing that your client prefers a particular room in your clinic, you rearrange your schedule so that they can be accommodated.
Location of treatment: A client asks if you can give them a treatment in their home, as they are unable to travel to the clinic.
Gifts: A client who has come weekly for eight years begins to bring you a calendar of photos of your favorite pet every year. This becomes a yearly ritual, and you begin to feel uncomfortable.
Services: Since so many of your clients have asked you to do so, you decide to give natural-foods cooking classes for a small group of them using your own kitchen, as it is well-suited to a class such as this.
Language: You find that with a particular patient, you often use language that might be considered inappropriate in a health care setting. For example, when you drop an instrument on the floor, you say "dang." You intend to be joking by doing so.
Clothing: As a rule, you ask patients to disrobe for their treatments. You cover them with sheets and towels, uncovering the areas that you need to access for treatment. You have them keep on their underwear. However, in some cases, you have patients who are not wearing underpants. A male patient warns you ahead of time that he is not wearing them and you consider how to respond.
Self-disclosure: Your patient asks if you got into the profession of acupuncture due to having had a personal health benefit from the treatment.
Physical contact: A patient of the same gender as you has had a very difficult and painful time with a family matter. You have worked with them over the years and feel you have become close with them. After a session in which the issue was discussed during the treatment, you offer the patient a hug before they go out the door.
Hopefully, this article has offered some food for thought. I think Martinez' model is a good one to apply to these tricky situations that arise so often in our profession.
- Martinez R. A model for boundary dilemmas: Ethical decision-making in the patient-professional relationship. Ethical Human Sciences and Services 2000;2(1):43-61.
- Gutheil GT, Gabbard GO. The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. Am J Psychiatry 150:188-96.
Click here for previous articles by Laura Christensen, MA, LAc, MAc.