Should Doctors Treat Family and Friends, Even If Ethics Codes Say Otherwise?

— AMA unmoved by Missouri surgeon's proposal to soften code of ethics

 A photo of surgeons performing rhinoplasty surgery.

A few years ago, plastic surgeon Edmond Cabbabe, MD, was preparing for a follow-up cosmetic procedure on his wife. Mercy Hospital South, a major hospital in St. Louis, Missouri, had put her on the operating room schedule, just as it had done when he operated on her before.

But on the day of surgery, Cabbabe said, the hospital called him and cancelled her procedure. Administrators told him the hospital's new policy would not allow physicians to operate on family members, he said.

He tried other hospitals where he had operated on family members before, only to learn that they, too, had changed their policies. In St. Louis, "all of the hospitals now have a sudden ban on us doing surgery on family," he said.

Ever since, Cabbabe, past president of the Missouri State Medical Association and the American Medical Association Foundation, has gotten increasingly angry. He thinks such prohibitions are way too strict. What's more, he said, some doctors perform surgeries on family members in much less safe settings: 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," Cabbabe said.

At the American Medical Association (AMA) annual meeting in Chicago earlier this month, Cabbabe went to the microphone to complain. On behalf of the Missouri delegation, he proposed a 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 that strongly discourages physicians from treating family members 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 family member, that's fine -- as long as the treatment is in the same specialty 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 one case, an ophthalmologist's wife experienced uncontrolled bleeding from surgery that her physician husband performed in his office, blinding her in one eye, Cabbabe said. In another, a plastic surgeon's wife developed a pneumothorax during an in-office procedure and had to be rushed to the hospital.

The doctors were never disciplined, he said during a phone interview with app, because their wives did not complain.

Another case came to light earlier this month when the Santa Rosa County Sheriff's Office Florida plastic surgeon Benjamin Jacob Brown, MD, with second degree felony homicide/manslaughter by culpable negligence in the death of his wife, Hillary. She went into cardiac arrest while Brown was performing procedures on her in his clinic. The Florida Board of Medicine of lapses in his care of three patients, including his wife, and last month .

Cabbabe said physicians treating their family members is not exactly a secret. He knows 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," Cabbabe told app. "I've never had a complication, infection, or any problem whatsoever. Everybody's happy."

He said his family members insisted on him because they believe he's the best. Also, he said, expensive plastic surgery procedures are not always covered by insurance.

Little Support for Resolution

But Cabbabe's 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.

One physician, Eli Freiman, MD, a pediatric emergency physician in Newton, Massachusetts, speaking for himself, did support Cabbabe's proposal. Freiman acknowledged that he didn't hesitate to treat his own family with amoxicillin 3 months ago after his son's preschool reported that five students had been diagnosed with strep throat, and subsequently his wife and child developed symptoms.

"My wife wondered if we should pay $100 to take him to urgent care to have him swabbed, which he would have hated," Freiman said. "I said no because it was so abundantly clear that my child had strep throat."

"Did he feel better? He did. Do I regret it? I don't," Freiman said, adding, "For those of us who do this, I don't think it's unethical."

Mark Casanova, MD, alternate delegate 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 app 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, speaking for herself, told the AMA reference committee during a hearing at the meeting 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 family members," 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 in the Annals of Family Medicine referencing research that found 99% of physicians are asked by family members 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 members for a cold or a cough, a skin infection or a muscle strain -- things that don't require procedures," Rosen said. "But more complex things, like a family member being diagnosed with rheumatoid arthritis or neurodegenerative disease, most physicians in their right mind are not going to be attempting to treat family members for that and will refer to a specialist appropriately." Any procedure requiring anesthesia, he said, should be done by someone else.

Art Caplan, PhD, professor of bioethics at the NYU Grossman School of Medicine in New York, said the issue has loomed over physician practices for a very long time because despite lofty policies, doctors go ahead and do it anyway.

While some hospitals or practices would never allow surgery, chemotherapy, or even psychiatric care on a relative or family member, "sometimes they don't know because the doctor doesn't make it clear. ... It doesn't mean the scheduling nurse knows."

But 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," he said. Another issue is that the family member may not want to be treated by a spouse, parent, or son or daughter, but "feels pressure."

Caplan acknowledged that for minor issues -- 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."

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    Cheryl Clark has been a medical & science journalist for more than three decades.