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Dynamic Chiropractic – January 29, 2009, Vol. 27, Issue 03

The Impenetrable Boundary

By Stephen M. Perle, DC, MS

People cross many boundaries. There is the boundary around one's country. There is the permeable boundary of good taste. (Some people seem to relish crossing this boundary just for the shock value - think Don Imus or Howard Stern.) And in professional ethics, there is a special boundary between the patient and the doctor.

This boundary is one that maintains the doctor-patient relationship as a professional relationship, rather than the relationship friends have, or worse yet, a sexual relationship.

The doctor-patient relationship includes an imbalance in knowledge. Patients come to us because as doctors, we are part of the "learned professions." Professions are called that because the members of the profession profess to have knowledge. Patients pay us for our knowledge - both intellectual and psychomotor.

We doctors of chiropractic have specialized knowledge based on what we learn in school, through practice and continuing education programs, and by reading peer-reviewed literature. We have general medical information that likewise is not well-known by the laity. Finally, we have the knowledge of intimate details of a patient's life - granted to us by the patient to aid us in our role as the health care provider.

Granting us this knowledge creates additional vulnerability for the patient beyond the disadvantage of lacking professional knowledge. However, the patient appropriately expects that, as professionals, our use of both sets of knowledge will be done with their best interest in mind. As I've noted before, patients should have trust in what motivates our actions.1

Knowledge is power, and with this power comes great responsibility to use that knowledge for good. A very small minority in all health professions has used their knowledge to aid them in crossing the doctor-patient boundary. It seems that in recent years, the problem appears to have become more prevalent; or it may be that the 24-hour news cycle and the Internet have just increased the exposure of these cases. Nevertheless, Foreman and Stahl2 found that in California, doctors of chiropractic were more likely to have been disciplined by their board of examiners for violating sexual boundaries than medical doctors.2

Is this a problem with our profession or with the fact that the basis of our primary treatments involves touching our patients - chiro-praktikos, "done by hand"? I prefer to believe the latter. Given this, doctors of chiropractic must make sure that their intentions toward the patient cannot be misconstrued as going beyond the normal concern of a humanistic doctor. Some things doctors can do to help ensure that a false claim of sexual misconduct is not filed include:

  • proper informed consent (such as making sure the patient knows where and why you will touch their body);
  • appropriate gowning and good instructions about gowning (what to wear under the gown and how to wear the gown);
  • proper draping, when needed;
  • chaperones, when appropriate;
  • providing care only during business hours;
  • no double entendres or sexual jokes; and
  • no comments about a patient's personal appearance.

Let's be as clear as possible: Any sexual relationship between a doctor and their patient crosses a moral boundary into unethical conduct. This relationship is immoral even when the patient initiates the sexual relationship. This is because any allegedly "consensual" relationship that is founded upon an imbalance of power is inherently not consensual.

Such a sexual relationship will never be considered consensual by regulators or professional associations, and is a clear sexual misconduct by any definition. Sexual misconduct is for the gratification of the doctor, not the benefit of the patient. It not only destroys the foundation of the doctor-patient relationship, "trust," but also immensely and immeasurably harms our profession as a whole. This is the impenetrable boundary.


  1. Perle S. "Credat Emptor." Dynamic Chiropractic, Jan. 1, 2003.
  2. Foreman SM, Stahl MJ. Chiropractors disciplined by a state chiropractic board and a comparison with disciplined medical physicians. JMPT Sept 2004;27(7):472-7.

Click here for previous articles by Stephen M. Perle, DC, MS.

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