By Sarah Ruth Bates, MBE
Zachary S. Sager, MD
A recent Ethics Case Conference at BIDMC focused on when it is and isn’t appropriate to hug patients. “There was an instance of a physician who didn’t hug a patient, left the room, and thought, I didn’t hug this patient, and I normally do. Why didn’t I? They felt that the gesture could have been misconstrued,” says Zachary S. Sager, MD, palliative care fellow at BIDMC and a panelist for the case conference.
Power Dynamics
Katie P. Rimer, MDiv, EdD, BCC
The conference focused on the ways that power dynamics, such as those present in the patient-physician relationship, can complicate and shape even well-intended overtures. The #metoo movement has helped to make those dynamics visible. This is not to equate hugging a patient with the harassment and abuse that #metoo has unearthed. But discussions of that harassment and abuse have illuminated subtle ways in which power dynamics alter the valences of our actions, whether at a movie set, in an office, or at a hospital. “We need to pause and think about why and whether we should touch patients: What will be the impact of this touch?” says Reverend Katie P. Rimer, MDiv, EdD, BCC, another conference panelist.
Cultural Awareness
Ethicists consider factors that others may not, such as cultural awareness. Rev. Rimer, who directs spiritual care and education at BIDMC and cares for a diverse population of patients, says, “It is customary in most Christian traditions to hold hands when you pray, and that is not customary for Jews. Similarly, in Buddhism, touch depends a lot on the status and relationship between the two people. A monk could touch the forehead of a patient, but not the other way around.”
Past Trauma
Individual patients’ pasts — their disclosed and undisclosed personal histories — also matter. “Trauma-informed care” asks clinicians to “presume someone has been through trauma and then act accordingly, which would certainly point us toward not presuming to touch,” says Rev. Rimer.
Weighing Moral Principles
Ethicists tackle dilemmas such as this by identifying the relevant tensions. In this case, Rev. Rimer says, the goal is to find “guidelines that are respectful of people while preserving the intimacy, and sometimes healing, that comes from touch.” In terms of principles, that means respecting patients’ autonomy, and honoring the principle of nonmaleficence — not causing harm — while also weighing beneficence, the duty to provide the best possible care. The very fact of hospitalization compromises patients’ autonomy, as does the patient-physician power dynamic.
Best Hugging Practices
Betsy Lowe
If physicians stop hugging their patients entirely, however, they may lose a valuable element of care. “Hugging them conveyed my condolences, and made me feel less doctorly and more human,” says Dr. Sager. Rev. Rimer agrees: not hugging a patient “could be withholding optimal care.”
What’s a doctor to do? The panelists suggested nonphysical ways of offering comfort, as an alternative to hugs. “Just me being present, and being silent, and saying that I’m sorry for your loss, can convey the same level of emotion as a hug,” says Dr. Sager.
James E. Sabin, MD
They also agreed on asking patients verbally before offering a hug. “If you ask, you empower the person, and it can open up a conversation,” says Dr. Sager. “It makes medicine relational.” Betsy Lowe, a BIDMC patient advisor, and also a panelist, recalls a physician asking her if she wanted a hug. “I felt strong enough to say, actually, no, that wouldn’t be helpful. If he had offered me a hug without asking, I probably would have just received it, and would not have left feeling any more comforted than before.”
Lachlan Forrow, MD
James E. Sabin, MD, director of the ethics program at Harvard Pilgrim Health Care, offered another best practice: an “A-frame hug, with no chest-to-chest contact.” That posture allows for “a gesture with minimal actual bodily contact,” while still providing comfort.
“Nothing therapeutic in medicine has zero risk,” says Lachlan Forrow, MD, director of ethics and palliative care programs at BIDMC, “but everything should be done carefully and respectfully.” Such dilemmas are “not rocket science,” says Dr. Sabin. “Our response should ideally match what we would come up with if we were reflecting on this situation in a leisurely discussion.”
The reporter has a master of bioethics from Harvard Medical School.
