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Exploring the Ethical Challenges in Working with Diverse Couples in Primary Care

Posted By Tina Schermer Sellers, Wednesday, September 28, 2016

Tina will host a Masters Lecture at the upcoming 2016 Annual Conference in Charlotte.  


It’s 9 am and you are already behind. Bob, 56, is on your schedule. It’s a follow up for his diabetes and blood-pressure. You have seen Bob, his wife Anne, and their three kids for over ten years. As you walk in, Bob seems anxious. You talk about the local football team, how the kids and Anne are doing, and then about his issues. You ask about how he is doing generally. Bob says he is really slammed at work and has been traveling a lot.


He then says, "Hey doc, we’ve been friends a long time, right?” "Yea, I’ve been seeing you for a long time”, you answer. "Well”, Bob continues, "I need you to keep a secret. I need you to run a little test for me. You see, I have this weird burning sensation when I pee, and I haven’t exactly been faithful. But you can’t tell Anne!” "Holy crap”, you think, "I saw Anne on my schedule for her annual this afternoon!”

In the hamster wheel that is primary care, clinicians master the art of moving and thinking fast - morning until night – except for those precious moments when they give patients their expansive attention. But the expansiveness stops there. If the provider is impacted by an ethical dilemma, where is the time to process this? If there were time, is consultation encouraged in the clinic culture? If it is, who is available to consult?


Dilemmas such as these come in many forms, from patients presenting lifestyles that conflict with the provider’s beliefs and values, to being placed in a triangle. A patient might consent to something that puts their emotional or physical health in danger or a loved one might make a choice for a dying patient that you disagree with, or another family member disagrees with. There are many situations that potentially fall outside the realm of what is clearly defined by a clinician’s guild.

For example, do you know how to deal with the kink couple who has a fetish that involves injury? Would you be able to distinguish this from abuse? What kinds of questions would you ask to be sure consent was being given versus coercion? How do you feel about treating a transgender adolescent? What if their parent is against their transition? How do you feel about treating a gender fluid teen? What if you had a patient with a rare benign brain tumor that went metastatic and now looked like it would be fatal, but she was refusing to tell her teen daughters and forbidding her husband to tell them also?


Do you know how to deal with the kink couple who has a fetish that involves injury? 

Since it is impossible to prepare for all ethical dilemmas that might confront the clinician in primary care, the provider must broaden their awareness of what triggers their reactivity in the face of ethical dilemmas, and closes their curiosity and openness – a kind of provider self-inventory. This is done through two primary avenues. First is to explore key beliefs and values that inform their spirituality or sense of truth, and examine the positive and negative sides of these beliefs with regard to how they influence their work as a clinician.


Second is to stay focused on their concern for the health and well-being of their patient and of the family system. To do this, they ask open-ended questions about how well-being is or is not being maintained, and the potential dilemmas being imposed. Beyond these two avenues, it is important for the clinician to create strategies to support themselves. These kinds of situations take an emotional toll. Strategies both at the clinic, and outside of the clinic, must be in place to restore and renew the provider if they are to thrive as a healer.

Come explore as we unpack the wild and mysterious underbelly of primary care, where the clinician’s heart meets the patient’s autonomy … and they don’t see eye to eye.

Tina Schermer Sellers, Ph.D., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member of the Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist and Supervisor for AASECT. 

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