Virtue Ethics in a Value-driven World: Patient Bullying—Does the Patient-Physician Relationship Change the Boundaries of Acceptable Interactions?

I was venting to a nonmedical friend about a lousy patient phone call. The patient was upset and threw several four-letter words in my direction, made negative statements about my integrity, and made it clear that I had ruined the patient’s life. Instead of my friend amiably offering support, she asked with a bit of horror, “Why would you let anyone treat you that way?”

The question pulled me upright. Why indeed?

This was not the first time a nonmedical person had questioned how I permitted my patients to treat me. Once, my husband asked about a bruise on my hip, and I recounted how an intoxicated patient had deliberately kicked me after I reduced his dislocated ankle. I was wearing my bruise as a badge of toughness, whereas my prosecutor spouse reframed the incident as an assault.

The Ethical Quandary of Patient Bullying

Much has been written on physician-nurse, nurse-nurse, and attending-resident bullying and abuse. Clearly, bullying is not ethically interesting—it is simply wrong. But the question as to why I permitted such bullying created an ethical quandary.

If my physician assistant or staff member had been treated in such a manner, I would have, and in the rare occasions where this has occurred have, unequivocally intervened and informed the involved patients that they could not treat my team members in this manner. When this has occurred, I’ve explained that we provide patients with respectful care, and in exchange there is an expectation of civility, at a minimum.

Likewise, when I had a Black resident team member in the office, and a patient asked me to not have Black residents care for them during planned elective surgery, I had no difficulty telling the patient to seek care elsewhere. This patient’s request was not one I was willing to honor.

Why then did I permit myself to be treated in a way that I would never allow my team members to be treated?

I think it was because I did not have clear, established boundaries as to what patient behavior I am unwilling to tolerate. I have these boundaries for others—I will not permit my residents or other team members to be yelled at, cursed at, or kicked by a patient. In the case of an upset patient after surgery, I consciously or unconsciously felt that I deserved—or at least was required to accept—maltreatment from the patient.

Ethical Guidance About Patient Behavior Is Limited

Medical ethics is generally focused on the positive obligations of a physician to a patient. We care for patients according to well-established principles like avoiding preventable harm (nonmaleficence) and promoting the patient’s best interests (beneficence) in a values-concordant fashion (respect for autonomy). The disproportionate power that physicians hold in the patient-physician relationship creates these obligations as a means to ensure that power is not abused and that patients are protected. It is easy to find extensive writing on the ethical obligations of physicians to their patients. But I have found myself struggling with the lack of ethical guidance regarding being verbally assaulted by an unhappy patient.

The American Medical Association’s Code of Medical Ethics Opinion 1.1.4 outlines a list of patient responsibilities [1], which are morally derived from the concept of autonomy and self-governance. In this AMA document, several responsibilities are described, based on responsibilities derived from the exercise of self-governance, or the principle of autonomy. One of those responsibilities would seem to address this issue: “Refrain from being disruptive in the clinical setting” [1].

Rather than a positive obligation, as physicians have to respect the autonomy of their patients, patients instead have a negative obligation: to avoid disruptive behavior. And to some degree this seems right—patients are necessarily vulnerable to the inherent power imbalance of the relationship. Perhaps it is fair to expect physicians to permit objectionable behavior because of our patients’ vulnerability. But is this really a part of the patient-physician contract? Viewed from a contractual perspective, does being in the role of a patient relieve a person from his or her responsibility to treat others with a modicum of civility?

In daily interactions, human relationships have boundaries. Society requires rules, both spoken and unspoken, to function. Although uncivil behavior may be on the rise—see the increased rate of unruly passengers on airplanes [5]—this does not excuse the bad behavior. Even when in the role of a patient, autonomous individuals must own their behavior. It seems reasonable that patients should receive more leeway for their behavior. Patients are often in pain and distress, and few of us are our best selves when in the patient role. However, it seems to me that my nonmedical friend also had it right: I had no obligation to remain in a situation where I was being bullied. It may be nice if I am able to absorb the patient’s anger with the goal of relieving her distress, but I have no obligation to do so. In fact, I have an obligation to avoid such abuse if it is harmful to me, particularly if such abuse might limit my ability or willingness to care for others.

Establishing and Maintaining Boundaries

Part of medical training involves inoculating ourselves against normal human responses to challenging situations. We are trained to not respond negatively when patients disclose embarrassing personal information, we don’t flinch when we see a fungating wound, and we have learned to stay calm in the face of the distress of other human beings. Yet, this instinct to stay engaged and present may result in self-harm. It may be generous of a physician to absorb a patient’s verbal bullying unflinchingly if an individual is so privileged that this abuse is not harmful, but recognizing that physicians are also humans, and our noses bleed when fists make contact, we are obligated to establish and maintain self-protective boundaries, to ensure we have resources for ourselves as well as our other patients.

The limits of one’s boundaries is individual to each physician and relative to each physician’s lived experience. There is evidence that women and under-represented minorities are much more likely to be harassed and bullied [2-4, 6-8]. Therefore, women and underrepresented minorities may require more expansive boundaries to self-protect, as they bear a greater burden of patient abuse. Virtuous physicians recognize that their professional responsibilities are not only to the patient in front of them, but also to themselves, as physicians distressed by patient bullying will be more limited in the care they provide to other patients.

But practically, extricating oneself from a challenging encounter is easier said than done. For difficult interactions, scripts can be helpful. If I could replay my interaction with the patient, I now wish I would have said: “I hear that you are upset, but I am not able to continue in this conversation with the language you are using. I am hanging up the phone now. We can speak later when you feel more calm, so that this conversation will be more productive.”