Abstract
Sexual relations within professional relationships is an important issue that receives and deserves public and professional attention. For psychiatrists, the relationships of concern are between psychiatrist and patient, and between psychiatrist and trainee. In both these relationships, there is potential for exploitation. Ryan [1, [2]] has usefully provided ‘a map of the ethical territory’ but the issues he raises beg further examination. In this paper, I examine the arguments concerning the ethics of consensual sexual relationships between psychiatrists and trainee psychiatrists but reach a different conclusion to Ryan [2]. The reason for this is a different view of autonomy, a developmental understanding of training and a consideration of a ‘duty of care’ incumbent upon psychiatrists in relation to trainees.
The argument for prohibition
Ryan presents the arguments that sexual relationships within a current supervisory relationship should be proscribed. These are essentially utilitarian, asserting that such relationships have deleterious effects on the psychiatrist's ability to supervise effectively as well as on the trainee's clinical performance. These result from a supervisor perhaps being unwilling to offer critical feedback or being unable to see errors or weaknesses in the trainee, and from a trainee withholding important information from supervisory scrutiny. In other words, such a relationship may be detrimental to psychiatrist, trainee and patient. Ryan finds these arguments ‘compelling’.
However, in regard to a general prohibition on consensual sexual relationships between psychiatrists and trainees (including those in no direct or current supervisory relationship) he does not find the arguments compelling. The arguments presented for prohibition are: (i) that there is an inequality of power between psychiatrist and trainee which makes a sexual relationship exploitative; (ii) negative consequences might accrue to the trainee such as an embittered psychiatrist inhibiting job prospects; and (iii) transferential qualities inherent in the relationship impair the ability of a trainee to properly consent. On the surface, these might appear strong arguments. However, the first argument is countered by a comparison with relationships between doctors and nurses, and between executives and secretaries. In these circumstances, there is a power differential while sexual relations are condoned. The second argument is trumped with reference to a right of autonomy that allows a person to make his or her own choices even if such choices are likely to be harmful. The third argument is dismissed with a truism that all relationships have an element of transference. ‘When examined critically, none of the arguments for a general prohibition on sexual contact between psychiatrists and trainees carries sufficient weight to overturn the assumption of a right to autonomy. The strength of the argument from the right to autonomy and the relative weakness of the arguments for proscribing such contact suggest that, in general, there is no ethical barrier to a psychiatrist and a trainee psychiatrist embarking upon a consensual sexual relationship’ [2, p.389].
Ethics, secularism and democracy
This conclusion highlights a number of characteristics of late 20th century ethics. The first is that it is a matter of opinion. Whether one finds an argument ‘strong’ or ‘relatively weak’ depends on one's point of view, one's values, assumptions or disposition. Often these values and assumptions are not stated and yet they determine how one sees the balance of arguments [3]. In our secular, post-modern, post Christian era there are few, if any, agreed rules or values. It is in this environment that ‘professional ethics’ is seeking to establish some agreement regarding professional behaviours, to restore a collective ethos. Sociologists such as Durkheim have described how difficult, and yet important, this is [4]. His concept of ‘anomie’ describes the social breakdown consequent upon the loss of this collective conscience. It is for this reason that discussions of professional ethics are so important.
The second characteristic of current ethical debates is the elevation to supreme status of the value of individual autonomy. ‘The right to autonomy is a powerful maxim. It is the right to autonomy that underlies the notions of consent, the right to freedom and democracy itself’ [2, p.388] (also [1, p. 172]). Few would argue with the importance of respecting a person's autonomy and the value of democracy. Democracy is, as Carroll asserts, ‘one of the sources of vitality and resilience that has saved modern Western societies from decline’ [5, p.171]. However, respect for individual autonomy alone does not make for a strong democracy. Studies, both in America [6] and Europe [7], have shown that the hallmarks of strong democracies are civic associations, voluntary organisations and traditions. These, together with an independent judiciary and a free press, are necessary to counter rampant individualism and enable a stable democratic society. These observations are important as psychiatrists as a group seek to define a voluntary code of behaviour in a way that will encourage a community's trust and respect and facilitate their clinical and educational roles.
Autonomy
The concept of autonomy warrants further attention. In common usage, it implies ‘being one's own person or being able to act according to one's beliefs or desires without interference’ [8, p.267]. It requires the capacity to think rationally and to make a reasoned decision consistent with one's values, and the ability to think and act freely, without undue influence from others. Autonomy can be frustrated either by external forces (loss of liberty) or by one's own capacities (agency). Respect for autonomy means acknowledging and honouring persons' rights to hold views, to make choices and to take actions based on their personal values and beliefs. To violate a person's autonomy is to treat them as a ‘means’ rather than as an ‘end-in-themselves’.
It is a fundamental characteristic of Western societies that we respect a person's right to exercise her ability to make independent decisions governing her life. We maximise individual liberty. However, a consideration of autonomy must also examine the extent to which the degree of agency is limited. In boundary violations, it is not just the explicit power that must be considered but also the vulnerabilities of the individuals that impair autonomous action. Ryan acknowledges these vulnerabilities in his discussion of transference and its effect on freely given consent. However, he dismisses its relevance, except as a reason for voluntary abstention, suggesting that ‘all relationships have an element of transference associated with them’. I believe he is right in this last point, but would suggest that this is a reason for more concern, not less. In particular, we should be cognisant of the particular nature and forms of transference relationships that are likely to occur between psychiatrist and trainee and how these might lead to inequality in relationship and impairment of true freedom of choice.
Training as an apprenticeship: a developmental perspective
Ryan makes comparisons between the relationship of psychiatrist and trainee with those of executive and secretary, and doctors and nurses. He implies that there is nothing of concern in these relationships and challenges the reader to show why the psychiatristtrainee relationship is different. He did not include the teacher-pupil relationship as an example of a similar kind of relationship, although that might have been a better one. The training to be a psychiatrist is an apprenticeship where a neophyte is attached (apprenticed) to qualified psychiatrists for teaching, mentoring and demonstration of what it means to be a psychiatrist [9]. These relationships have potential dangers occurring because of the structural power imbalance inherent in them [10]. In addition to education and clinical guidance, supervision provides opportunity for self-reflection and development as a psychiatrist (as a person) through the processes of healthy idealisation and internalisation. This very personal aspect of the relationship also provides an avenue for the expression of competitive rage, narcissism and various other qualities. What is important is that the psychiatrist is expected to be aware of these matters; the beginning trainee is not. This bestows upon the psychiatrist a duty of care, similar to that which a teacher has. For the beginning trainee there is the possibility of autonomy being limited by both external power (loss of liberty) and personal capacity (agency). The former must be rejected; the latter respected. However, as the mentoring proceeds the trainee will be becoming more of a psychiatrist. This involves learning the clinical skills as well as developing the professional and ethical values of a psychiatrist. Reflection upon the nature of the supervisory relationship and the qualities of the psychiatrist will be important in this development and in understanding professional roles and relationships. As an apprentice, the trainee begins a pupil, but becomes a colleague. That is perhaps why the American Psychiatric Association can say that consensual sexual relationships between a psychiatrist and senior trainees is ‘not necessarily unethical’ [11].
Some writers believe the distinction between a current supervisory relationship and a past or indirect one important. Ryan argues this, and suggests therefore that supervisors in or contemplating a sexual relationship with a trainee could resign their direct supervisory role and continue the sexual relationship. An important consideration is whether or not the issues described above are applicable in an indirect supervisory situation. Is there a capacity for impaired autonomy (liberty and/or agency) where there is no direct supervision, and does a duty of care exist for psychiatrists in this situation? Alternatively, do these cease to exist once direct supervision finishes?
With regard to psychiatrist-patient sexual contact, Ryan and Anderson [1] suggest that the distinction of currency of relationship is not ethically important and argue in that circumstance a prohibition should continue indefinitely post-termination. This argument rests on what they call the ‘principle of confidentiality’, although it would, I consider, be more correctly called the ‘principle of trust’. In this it is argued that open sharing from patient to therapist is an important therapeutic ingredient and will only occur if a patient trusts her or his therapist. With regard to the issue of sexual contact, this means trust that the growing intimacy that develops as a consequence of sharing one's feelings, hopes and vulnerabilities will not be confused with a social intimacy and that a professional relationship will be preserved.‘The erosion of this principle would mean that patients could not feel safe in the knowledge that the intimate therapeutic relationship will remain only that. With the possibility of a sexual relationship in the back of their minds, patients will hold back with their therapists, and the intimacy so vital to the enterprise will be lost. The inevitable result would be the diminution of clinical care of all patients and poten tial patients. On utilitarian grounds, the harm done by the loss of community confidence in the principle will far outweigh any good that might come out of the individual relationship, even in the unlikely event that the particular patient were to benefit substantially’ [1, p. 174]. In other words, the trust that any individual patient has will be affected by the reputation generally that psychiatrists hold. Hence, for the greater good, that is for trust to be maintained for future patients, individual autonomy should be restricted.
This argument is directly applicable, I believe, to the training of psychiatrists. For trainees to benefit fully from the learning experience, a degree of vulnerability and exposure is required. This demands that they are able to trust that their seniors will be respectful and caring in their responses. This requirement of trustworthiness is bestowed collectively upon psychiatrists and is not specific to a direct supervisory relationship, although it is critically important in each. If a trainee does not have a general trust in psychiatrists, he will avoid teaching and supervision, contribute little, and consequently learn little. In addition, he will be loath to develop the depth of relationship that would facilitate his development as a psychiatrist, as it is in the interpersonal dimension of supervision that the personal and ethical aspects of the formation of a psychiatrist occurs. Trainees will hold back with their supervisors and ‘the intimacy so vital to the enterprise will be lost’.
Special cases
This principle is acknowledged to be important by Ryan in two ‘special cases’ where he suggests prohibition could apply and autonomy be over-ridden. The first is the ‘Don Juan’ who is involved in repeated sexual relationships with trainees. Other trainees would be wary of developing a meaningful relationship with this psychiatrist and this would inhibit the supervisory process and impair both learning and clinical work.
The second ‘special case’ is when a group of psychiatrists, for no particular reason other than they think it a good idea, covenant to abstain from sexual relations with trainees. ‘A psychiatrist who indulged in sexual contact with a trainee after voluntarily taking such a pledge would then be breaching a promise made to all the other psychiatrists of the group and to all the trainee psychiatrists who were attracted to the group because of that promise. Such a breach of faith would attract ethical disapproval, both in its own right and because it would undermine the nature of all other psychiatrists’ pledges and thus cause harm to the psychiatrists who made the pledges and to the trainees who trusted in them’ [2, p.390]. In this case autonomy has been freely given up. ‘One is always free to waive one's right to autonomy’ [2, p.390]. This is an interesting point of view, when contrasted with society's general acceptance of broken promises of fidelity. Nevertheless, it is hard to see how making a voluntary pledge and deciding not to indulge sexual attraction is giving up a right to autonomy. To the extent that the decision is reasoned and consistent with one's values, made freely and without undue influence from others, it should be considered exercising autonomy to the full. However, it does go to the core of the issue in professional relationships: the matter of trust. How will trainees trust that their supervisors will not abuse professional privilege and power? If only some psychiatrists take the pledge how will they be known? Or conversely, will the supervisors who do not take the vow be identified!
Although it is clear that Ryan's suggestion (a generally permissive approach allowing voluntary abstinence) is designed to maximise individual freedom it does seem problematic. It cannot be avoided that good supervisory relationships do not occur in a moral vacuum but in a setting that establishes mutual trust and respect between psychiatrists and trainees. Trust is not simply an individual attribute but also an institutional one. One of the defining characteristics of a professional group is the traditions and corporate values it upholds. That is how members are known, and it is by virtue of these that any person (a patient or a trainee in this case) initially bestows his or her trust on a member. It is, therefore, important that there are agreed standards and principles. I suggest that a conservative policy of restraint would create a tradition of corporate trustworthiness and diminish some of the ambiguities in the training environment.
If this were accepted, however, there are other ‘special cases’ to be considered. The most obvious is when a spouse of a psychiatrist joins the training program. This may not be common, but highlights a limitation of the discussion so far; that is, a consideration of relationships and factors outside those of the immediate supervisory and training relationships. Other factors may be age, maturity or experience; things that might make one consider a relationship, in some way, collegial. Such considerations make it difficult to create rigid rules to define appropriate and ethical behaviour. That is not to say that there are not ethical and unethical relationships, but that a judgement of what is an ethical relationship cannot be made in isolation from a consideration of other relationships and commitments, external to the structure of supervision and training, that persons hold.
Conclusions
Ryan has usefully identified the issues involved in the ethical consideration of consensual sexual relations between psychiatrists and trainees. In this paper, I reach a different conclusion, arguing for a general prohibition on sexual relationships between psychiatrists and trainees. The basis of this is twofold. First, is a consideration of the developmental nature of the formation of a psychiatrist and the consequent impairment in the exercise of autonomy that this brings, particularly to young trainees. The strength of this as an argument for prohibition weakens as a trainee approaches the status of colleague. Second, I argue that sexual relations between psychiatrists and trainees are detrimental to the general trust necessary for good supervision and an unambiguous training environment and that a general principle of restraint will reduce anxieties and increase trust. Finally, I suggest that an ethical judgement on the matter of consensual sexual relations cannot be made without a consideration of relationships, commitments and factors external to the supervisory and training environment.
Footnotes
Acknowledgements
Frances Thompson-Salo kindly read and commented on an early draft.