The question of whether doctors should be allowed to treat – and operate on – close friends and relatives is a controversial one, and in the United States, an increasing number of hospitals are now changing their policies and banning this, notes MedicalBrief.
Irate Missouri plastic surgeon Edmond Cabbabe said he was preparing for a follow-up cosmetic procedure on his wife, who was on the Mercy Hospital South operating room schedule – as she had been when he operated on her before.
But, reports MedPage Today, on the day of surgery, the hospital called him and cancelled her procedure. Administrators told him the hospital’s new policy would not allow physicians to operate on family, he said.
He tried other hospitals where he had operated on relatives before, only to learn that they, too, had changed their policies.
Cabbabe, past president of the Missouri State Medical Association and the American Medical Association Foundation, is furious, believing such prohibitions are way too strict.
What’s more some doctors perform surgeries on family in less safe settings, like their offices or clinics where there are fewer personnel, fewer quality checks, and where an adverse event would necessitate a transfer to a hospital that may not happen in time.
“The hospital is the best place for safety,” he fumed.
At the American Medical Association (AMA) annual meeting in Chicago earlier this month, Cabbabe took the stand and on behalf of the Missouri delegation proposed a resolution for adoption by the AMA House of Delegates.
He called for the AMA’s Council on Ethical and Judicial Affairs (CEJA) to “soften the language” in a section of its code of ethics that strongly discourages physicians from treating family except in extenuating or emergency circumstances, or for short-term, minor problems.
He said the AMA’s position should be that if a physician is appropriately trained in the relevant specialty and feels comfortable treating a consenting relative, that’s fine – as long as the treatment is in the same speciality as the physician’s training and skill, and performed in a hospital.
Hospital policies vary around the country, but a more lenient stance by the AMA could influence health systems that now prohibit family member procedures, he said.
Safety a key concern
Cabbabe told a reference committee considering his resolution that his key concern is safety. He recalled two cases in St Louis in which preventable harm occurred: in the first, an ophthalmologist’s wife experienced uncontrolled bleeding from surgery that her physician husband performed in his office, blinding her in one eye.
In another, a plastic surgeon’s wife developed a pneumothorax during an in-office procedure and had to be admitted to a hospital.
The doctors were never disciplined, he told MedPage Today, because their wives did not complain.
Another case came to light earlier this month when the Santa Rosa County Sheriff’s Office charged Florida plastic surgeon Benjamin Jacob Brown, MD, with second degree felony homicide/manslaughter by culpable negligence in the death of his wife.
She went into cardiac arrest while Brown was performing procedures on her in his clinic.
The Florida Board of Medicine has accused him of lapses in his care of three patients, including his wife, and last month ordered an emergency restriction of his licence.
Cabbabe said physicians treating their relatives is not exactly a secret – that many do so safely, even when it’s not an emergency or an extenuating circumstance.
“I’ve done surgery on my wife in multiple hospitals before, on my children and my daughter-in-law,” he added. “I’ve never had a complication, infection, or any problem whatsoever. Everybody’s happy.”
He said his family insisted on him because they believe he’s the best. Also, expensive plastic surgery procedures are not always covered by insurance, he conceded.
Little support for resolution
But his proposal is controversial. The AMA reference committee that considered his proposal didn’t give him much support, and the House of Delegates did not adopt his resolution.
Mark Casanova, MD, from Texas, said he was neither for nor against the Missouri resolution, but noted many state licensing agencies have varying policies.
For example, the Missouri Board of Registration for the Healing Arts told MedPage Today that under its rules, “a physician has the same obligations and responsibilities, in regard to the treatment and care of a patient, under the statutes and regulations regardless of whether or not a familial relationship exists”.
Kathryn Skimming, MD, a former member of the CEJA task force, told the AMA reference committee that she opposed changing the policy.
“Physicians don’t do a great job all the time of getting away from bias when treating themselves or when treating their family,” she said. Besides, the council’s policy allows “for exceptions, for minor or time-limited problems, or situations where there’s no other qualified physician”, she said. “The guidance is there if you look at it.”
Most docs do it
Cabbabe said doctors feel the pressure. He pointed to a 2018 article in the Annals of Family Medicine referencing research that found 99% of physicians are asked by family for medical advice, diagnosis, or treatment, and 85% have written at least one prescription for a non-patient.
Ethics experts say that generally, doctors should avoid treating family or close friends.
“The devil’s in the details,” said Charles Rosen, MD, a spine surgeon at the University of California Irvine who is also president and founder of the Association for Medical Ethics.
“I think doctors can reasonably treat family for a cold or a cough, a skin infection or a muscle strain – things that don’t require procedures. But more complex things, like a relative being diagnosed with rheumatoid arthritis or neurodegenerative disease… most physicians in their right mind are not going to attempt to treat family for that and will refer to a specialist appropriately.”
And any procedure requiring anaesthesia, he said, should be done by someone else.
While some hospitals or practices would never allow surgery, chemotherapy, or even psychiatric care on a relative, “sometimes they don’t know because the doctor doesn’t make it clear”, said Art Caplan, PhD, professor of bioethics at the NYU Grossman School of Medicine.
He listed several reasons why it’s a bad idea. “You run the risk of a family member not being honest with you … and there’s a risk of not being objective. Additionally, that person may not want to be treated by a spouse, parent, or son or daughter, but feels pressure.”
Caplan acknowledged that for minor issues, like a prescription refill, for example, there’s lower risk. And of course, emergencies should be exceptions.
“But it’s hard to write a policy that way. It’s better to keep it as, ‘better not do it’. … The higher the stakes, the more dangerous it gets.”