Doctor-patient hugs: Is non-clinical touch a line you should cross?

Ethicists split on propriety of platonic hugs between patients and clinicians

Have you hugged a patient today? Whether your answer is yes or no, there will be disagreement about the wisdom of your choice.

Providers and patients agree the value of the human element in the delivery of health care and the caring relationship between physician and patient cannot be overestimated. Throughout the history of medicine, hands-on touch has been employed to administer comfort and, in some practices, to heal outright.

But is there a place in today's medicine for a comforting, empathetic hug between patients and physicians? Or do privacy issues, professional decorum, and lawsuits make non-clinical physical contact a no-no?

"I believe that healing, from a holistic perspective, has everything to do with caring," says J. Vincent Guss Jr., MDiv, a pastoral care and bioethics consultant in Alexandria, VA. "The most powerful and often most meaningful way of caring includes physical demonstrations, [such as] hand-holding, a hug, etc. In fact, every major religion includes touch in sacramental or less official demonstrations of healing, such as laying on of hands and anointing, or the 'kiss of peace' — usually without the actual kiss but including hugging and/or handshaking."

But Guss, along with other ethicists and clinicians who spoke with Medical Ethics Advisor, says that in modern society, a touch or a hug can mean many things — and not all of them are considered welcome or helpful.

Context can mean everything

"I absolutely don't think that physicians, as a rule, should get into the habit of hugging their patients," says Emory University ethicist John Banja, PhD.

Banja says how a hug between clinician and patient is perceived depends heavily on the context in which it's given and received.

Because most physicians perform physical interventions that involve the physical examination and manipulation of intimate body parts (i.e., rectal, pelvic, or breast exams), Banja says a hug or other social form of touching (hand-holding, back-patting) could be confusing.

"It sends a very mixed message to the family or to patients about how their relationship with the physician is supposed to go," Banja suggests. "Is he a friend? Or like a member of our family?

"And with that, the patient's or family's expectations of the physician may get very confused. So a hug — as opposed to a warm handshake — crosses the line for me. Hugging occurs among friends and family members as a token of affection. Physicians are neither friends, family members, nor others who have affectionate relationships with their patients."

However, Valley Forge, PA, family practitioner Lucy E. Hornstein, MD, doesn't see quite such a black-and-white distinction with some of her patients.

"My relationships with many patients are friendly, so our interactions often mirror those of other similar friendships in the community," explains Hornstein. "Age and gender play a role, of course, as do individual patient personalities. It's not really all that complicated; I'm sure you have friends you routinely greet with hugs and others you wouldn't dream of hugging under any circumstances. Same with me in the office."

But Marc D. Hiller, DrPH, associate professor at University of New Hampshire's department of health management and policy, believes that hugs between patient and clinician should be considered only when the provider has a "near absolute sense that the hug is really needed and will likely benefit the patient."

"I would also suggest that if it is to be considered at all, that it be clear that it is being done only as a consoling measure following the delivery of a significant negative prognosis for the patient or the death of a close family member [as] when that patient has no other person accompanying them who might be able to do so," Hiller clarifies.

Culture dictates appropriateness

A 2006 study conducted in Canada, in which family practice patients were asked their opinions of "comforting touch" in their medical care, revealed that a majority of those patients surveyed (66.3%) believed that the touch of their health care practitioners can be comforting, and slightly more than half (57.9%) believed that touch can be healing.1

That study polled primarily people of English descent. The authors point out that similar studies have suggested that cultures that tend to engage in tactile relationships (e.g., Spanish, Italian, Greek, Jewish, Latin and South American, and Arabian) are more receptive to comforting touch. Other cultures that are less likely to make tactile gestures, including English, Canadian, German, French, and Dutch, may not view non-clinical touch as an appropriate component of the health care relationship.

Some cultures frown upon — or forbid — touching, even in a clinical manner, if the patient and physician are of different genders. So a hug could be offensive to people of those backgrounds, Banja points out.

In his chaplaincy ministry, Guss says that if it appears that a patient or family member (or staff member) needs care expressed by a physical demonstration, he asks, "Would you like to join hands when we pray" or "May I give you a hug" (when the person is in grief or pain).

"Even when one asks and receives permission, there is still the risk of appearing inappropriate to someone else, [but] it is a risk I am willing to take for the sake of the patient or family member needing care," Guss explains.

But before he even asks the question, he assesses whether cultural circumstances would make the question itself inappropriate; for example, the interpretation by some orthodox Islamic cultures that it is a violation of a woman if a man, who is not the husband or father, comes into any physical contact with her regardless of circumstances.

"And so, I will not always offer such an expression to some people, even though in the same clinical circumstances I might offer it to others," he says.

Paul B. Hofmann, DrPH, president of Hofmann Healthcare Group, says asking "may I" before making physical contact can ensure that the gesture is given and received by all parties appropriately.

"We should not minimize how the beliefs, values, and needs of clinicians affect their interactions with patients and families," Hofmann says. "Providing comfort is a delicate matter for all the parties involved."

Despite all the reasons that care providers should use caution in dispensing physical comfort, Guss says there are strong reasons to administer touch when appropriate.

"Is it not an abuse of trust and an absence of quality of care to punish all patients and their families because of the crimes of a few?" he asks, referring to lawsuits and cases of abuse. "In many circumstances, people need to be hugged and physically reassured, especially at the time of loss of a loved one, a painful diagnosis or prognosis, in times of anxiety and pain."

Evaluate before hugging (or not)

Adding to the risk of mixed messages that can be conveyed by physical gestures is a heightened awareness of sexual harassment, real or perceived, says Guss.

"The reason is that there has been widespread abuse of the natural inclination to physically demonstrate care devolving into something not so beautiful and platonic," Guss points out. "Some health care professionals, like other segments of the population, have abused the trust of their patients in the most vulnerable of circumstances for their own pleasure and gratification."

Guss points to litigation seeking large financial damages for patients who have actually been abused as a factor that has motivated hospitals and other health care organizations to institute very strict policies limiting physical contact to only what is absolutely necessary to administer clinical care. Professionals consequently have become afraid to show care in any physical way that could be misinterpreted, he adds.

Yet Hofmann urges caution not only to protect the physician professionally, but to insulate the physician-patient relationship.

"Especially during a crisis, patients and families are very vulnerable," Hofmann says. "If a clinician is uncertain about the propriety of making physical contact, it is best to refrain. For example, if a clinician should fail to recognize the significant influence of cultural and other factors, any touching viewed as improper by the patient or family could cause irreparable damage to the relationship."

But as other experts point out, Hofmann says that to some patients, a physician who shrinks from physical gestures is "cold and aloof."

"Although caution should be exercised, there is still a perception among patients and families that too many clinicians seem aloof and insensitive to their emotional needs," he says. Hofmann says this concern is raised most frequently when patients approach the end of life, and emphasis shifts from aggressive treatment to pain and symptom management.

"Physicians particularly have been criticized by family members who felt abandoned because they thought the physician underappreciated the continuing need for visible and tangible support during this difficult period," he continues.

Family practitioner Hornstein says she hugs when she feels it's part of "the therapeutic interaction."

"My 'protocol' is to say, 'Do you need a hug?' in a neutral enough tone so that yes and no are equally acceptable answers, which I then honor," she says.

Hornstein says that contrary to what might be assumed, the patient most likely to be receptive to a hug is not a long-standing patient, but a new patient at the conclusion of a long, ultimately positive clinical interaction.

"Certainly, deciding whether or not to make the offer requires situational intuition — something that I believe I have or have developed over the years but am not sure if, or how, it can be taught," she adds.

Right or wrong, the rules are different

Though not that they should be, the rules of whose hugs are more acceptable are different based on age and clinical role, most experts said.

"I truly believe that there should absolutely be no difference whether a hug comes from a doctor or a nurse or anyone else," Guss asserts. "However, unfortunately, in this culture, a hug from a nurse, especially if the nurse is female, would be likely more accepted by many people than it would be from other professionals."

Hornstein makes no bones about it — there is a difference, she says.

"I freely admit that in our culture, my gender puts me at a tremendous advantage in this regard," she says. "Men in America do not routinely hug as part of any greeting ritual, except with very close family, so I can certainly appreciate a male physician's greater reticence to hug patients in the office.

"The consequences of making a mistake are much greater, too [for male practitioners]. As for me and my patients, it works for us."

Is a hug from a doctor different from a hug from a nurse? Banja suspects so.

"The nurse is really a gray zone. It's customary, or at least not unusual, for nurses to hug family members after the in-hospital death of a loved one, and no one has a problem with that," he says. "Yet it would still seem to me a blurring of roles for nurses to routinely hug patients or family members as part of their normal workday greeting to them."

Banja says regardless of the provider's role, "it is extremely important, I think, for health professionals to stay in their roles as professionals who diagnose and treat illness according to professional standards. Doing so requires objectivity and a certain kind of detachment, which is not incompatible with being empathic [but] that hugging, I believe, compromises."

Reference

  1. Osmun WE, Brown JB, Stewart M, et al. Patients' attitudes to comforting touch in family practice. Can Fam Physician 2000; 46:2,411–2,416.

Sources

For more information, contact:

  • John Banja, PhD, professor, department of rehabilitation medicine; medical ethicist, Center for Ethics, Emory University, Atlanta, GA. E-mail: jbanja@emory.edu.
  • J. Vincent Guss Jr., MDiv, advocacy commissioner, Association of Professional Chaplains; pastoral care and bioethics consultant, Alexandria, VA. Phone: (703) 404-5215.
  • Paul B. Hofmann, DrPH, president, Hofmann Healthcare Group, Moraga, CA.
  • Marc D. Hiller, DrPH, associate professor, department of health management and policy, College of Health and Human Services, University of New Hampshire, Durham. E-mail: marc.hiller@unh.edu.
  • Lucy E. Hornstein, MD, 1288 Valley Forge Road, Valley Forge, PA 19482. Phone: (610) 983-9299.