The ethics of looking after family and friends, a call for more helpful guidance and education

Guidelines in countries such as UK, USA and Canada are very clear that doctors must not give advice to those with whom they have a close personal relationship unless there are exceptional circumstances such as an emergency situation or when no other doctors are available. ^1,2,3,4,5 

However these guidelines can be problematic to interpret. For example the American Medical Association (AMA) guidelines  state that one is allowed to treat minor conditions but does not define a minor condition.⁴ Indeed, apparently minor conditions at presentation may not be so minor after all. In an Australian case, a simple request for analgesia following dental extraction led to a fatal outcome as the doctor family friend was not aware the patient was on an antidepressant that led to a fatal interaction with the analgesic.⁷

Some guidelines are better than others -the College of Physicians and Surgeons of Ontario (CPSO) guidelines give more details about definitions and scope of treatment.⁵

In some countries, such as India and Saudi Arabia, commonly-accepted societal norms actually encourage doctors to respond to requests from friends and family. Papers from both countries have highlighted the ethical issues this can pose and asked for medical education and guidelines for doctors and communities. ^8,9

Existing guidelines can be hard to interpret. The UK General Medical Council (GMC) guidelines simply state, ‘Whenever possible avoid providing medical care to yourself or anyone else with whom you have a close personal relationship.’¹Although this can be usefully permissive for individual flexibility, it can also result in confusion and blurred boundaries. This is reflected in the fact that in UK between 2020 and 2025 there were 389 complaints received by the GMC relating to doctors treating family and friends (personal communication from GMC under Freedom of Information act, 29/5/25).

Doctors are asked for advice on a range of matters ranging from simple factual information to actual medical care. Often this approach is informal, in contrast to a formal doctor patient relationship which is consensual in nature and based on contract whether expressed or implied. Blurred boundaries can be a problem as a  physician becomes involved with a family member. There is a dynamic tension between personal and professional roles. Where does one draw the line? How far should one choose to move the line in any particular situation? Blurred boundaries can pose a moral dilemma for the doctor and possible adverse outcomes for the patient.¹⁰

A systematic review by Biegel and others explored the reasons for and against doctors providing treatment to friends and family. They noted that many of the authors referred to existing codes of ethics but felt they were unhelpful, discouraging and insufficient as they do not help doctors facing real life dilemmas.¹¹

It is helpful to look at the reasons for and against intervention from an ethical perspective.

Reasons for intervening

Virtue ethics focus on the person performing the act, doing what one thinks is right and making wise and moral decisions in varying situations.

Doctors generally want the best possible care for their relatives. They have a knowledge of systems and pattern recognition that a non professional will not have. A doctor may notice that their friend/relative has a problem that requires further investigation or intervention.  They will want to draw their attention to it and signpost them to seek independent medical help. A doctor can also also be aware of their relatives and friends receiving substandard care or mistakes being made.They have the medical knowledge and understanding, the intellectual virtues, to help.

It is often the case that the relative/friend seeks out the doctor’s help with a problem and a doctor may wish to be helpful and engage with the conversation.  Compassion is a moral virtue valued by persons approaching a doctor for help.

Intervening requires good judgement. It may also require courage as raising the issue with a loved one may cause turmoil and disruption.

The correct application of these intellectual and moral virtues can be a reason for intervention.

Justifying reasons for intervention using the four principles approach from Beauchamp and Childers, requires the balancing of autonomy, beneficence, non maleficence, and justice.¹²

It can be argued that if a person prefers to seek out the advice of a doctor friend/relative, this expression of autonomy needs to be respected.

In terms of beneficence, the patient may well choose not to seek help otherwise. They may also approach their doctor friend/relative with problems at an early stage where early intervention such as urgent cancer referral can make a difference to outcomes. Even if a doctor does not directly look after their friends and family their access to contacts can ensure timely and correct intervention. It is convenient for people to seek advice from someone who is easily accessible.

In societies where it is culturally acceptable for doctors to look after friends and family looking after them can strengthen societal networks and there will be cost savings (for the patient) where patients are charged for their services.

It can be argued that it is not unfair or unjust to care for the person who has approached you if no-one else has suffered as a result of your intervention. This is especially if this is done outside ‘office hours.’ The gift of care has not been ‘taken’ from another patient from or an employer.

Though there are many more considerations, these may be enough to conclude that a doctor can be guided by strong ethical principles to justify giving such advice. They will be mindful of ‘doing no harm’ and  can argue that if in their judgement they have the right expertise to intervene and are not practising outside their skill set, there is no harm.

What are the risks of harm for a doctor giving advice to friends and family?

Using the four principles, the harms can be categorised as:

Emotional:

• Doctors have autonomy too and may prefer not to give advice when approached but feel under pressure to do so.
• They easily lose objectivity when confronted with illness in those close to them. They may be especially fearful of making a mistake and their anxiety can lead to over referral and overmedication. They can also blame themselves when things go wrong.

Practical:

• Often doctors are approached informally. The do not have their ‘doctor hat’ on and although they can put this on quickly if they have the insight that they have been approached for medical advice, it is easy to take inappropriate short cuts in history taking.
• It may be practically difficult to conduct a physical examination and there are major social and legal taboos around intimate physical examinations.
• Record keeping may not be as meticulous as when a doctor is formally at work. Advice can be misinterpreted or not followed correctly. Without adequate written records, this is difficult to challenge. 

Communication:

• The patient may withhold information and not wish to divulge full details of their problem and the doctor may be too embarrassed to ask probing questions.
• Confidentiality is an integral part of the doctor patient relationship but unless clarification is sought in this context, the person seeking advice may be unclear about whether the information will be kept confidential. It may also be a dilemma for the doctor -if the medical problem is something the extended family is aware of, what information, if any should be divulged?

Relationship:

• In a doctor-parent offspring relationship for example, the person receiving medical care may hand over decision making more easily to the doctor parent, undermining their autonomy and their own ability to make choices over treatment.
• The dynamics between the person and doctor can be affected if the person given advice does not follow it, with the doctor seeing it as a personal rejection.
• Doctors may be blamed by others in the family and friendship network if things go wrong.
• It also cannot be presumed that the doctor will always prioritise the best interests of the person they are advising. Even subconsciously, they may give greater weight to the consequences of any action for other family members or themselves.

Applying ethical principles in practice

One of Aristotle’s cardinal virtues is phronesis or practical wisdom, which entails judgement about the best course of action. The ability to make the right decision in any individual situation can be cultivated and reflection and education are essential as guidelines cannot cater for every unique situation. The risks of doing harm in the context of looking after friends and family can be significant but they do not negate the benefits of doctors advocating for friends and family in the right context.

Recommendations for medical education and reflective learning

How does one cultivate practical wisdom? Papers that have been written on looking after family and friends have come up with useful suggestions:

• Hutchinson et al suggest using case comparisons and thought experiments.¹³
• La Puma has a list of questions for doctors to ask themselves and the first is ‘Am I trained to meet my relatives medical needs?’ ¹⁴ This is very relevant if the medical professional who has been approached is a doctor in a speciality totally unrelated to the nature of the query or a doctor who is not working clinically or a medical student.
• Fromme asks the question one should ask oneself “Can I engage with this without a medical degree?” If the answer is ‘no’, caution should be exercised.¹⁵
• Fromme has also written a table on guidelines on low risk, medium risk and high risk interventions.Low risk includes helping to explain medical information such as a new diagnosis. High risk would include prescribing medication.¹⁵

Papers in speciality journals have also made specific recommendations relating to their speciality.^16,17

Even if one is trained to meet the requester’s medical needs, one still needs to consider how to proceed through critical reflection and consider potential pitfalls such as loss of objectivity, confidentiality issues and problems with inadequate history taking and examination.

A doctor can still provide benefit to their relative/friend by acting as an advocate and helping them navigate systems while other doctors provide the medical care.

This ethical learning and reflection needs to be included in undergraduate and postgraduate curricula and continuing professional education for doctors at all career and life stages.

This is a complex area that many doctors across the world face on a daily basis -better guidance is needed.

Guidance for doctors would be more helpful if it incorporates real world complexities. It needs to help doctors clarify their role. The reality is that doctors’ identity and knowledge are integral to their personhood and it must be recognised that it is impossible to take the doctor out of the person. There needs to be guidance for doctors giving them clarity on their role.

Being a doctor when a loved one is ill can be a very difficult place to be. Guidelines do not generally reflect the reality on the ground and in the main emphasise the  negative aspects of intervening. Arguably, there are times where intervention by a doctor in the care of friends and family can be the ethically correct action.

Better country-specific guidelines are needed to reflect some of this complexity.

There is also a need for education and reflective learning at undergraduate and postgraduate levels to help doctors make the best choices when someone with whom they have a close personal relationship needs medical intervention.

References 

1. General Medical Council. Good Medical Practice.Trust and professionalism. 2023. https://www.gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice/domain-4-trust-and-professionalism (accessed 20 March 2026).

2. BMA Ethics Toolkit The doctor-patient relationship 2024 [updated 2025] Treating colleagues, friends and family p 22 https://www.bma.org.uk/media/nalcxoal/doctor-patient-relationship-guidance-updated-feb-2025.pdf (accessed 20 March 2026).

3. Medical Defence Union. Risk in practice: treating friends and family. 2014. https://www.mddus.com/resources/resource-library/risk-articles/2014/september/risk-in-practice-treating-friends-and-family (accessed 30 March 2026).

4. American Medical Association. Treating self or family. Code of Medical Ethics. Opinion 2017 https://code-medical-ethics.ama-assn.org/ethics-opinions/treating-self-or-family  (accessed 20 March 2026).

5. College of Physicians and Surgeons of Ontario (CPSO). Treatment of self, family members and others close to you. 2001 [Updated 2025] https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Physician-Treatment-of-Self-Family-Members-or (accessed 20 March June 2026).

6. La Puma J, Stocking CB, LaVoie D, Darling CA. When physicians treat members of their own families. New England Journal of Medicine. 1991; 325(18):1290-4.

7. Bird S. The pitfalls of prescribing for family and friends. Australian Prescriber. 2015 Nov 6;39(1):11.

8. Vijayalakshmi S, Ramkumar S, Rajsri TR, Prasanna S, Rueban MP, Anand UP, Parasaran J, Kumar S, Vijayalakshmi Sr S, Sundaram R, TR R. A Doctor in the House, An Ethical Consideration on Treating Their Family Members: A Mixed-Method Study. Cureus. 2023 Aug 27;15(8). https://doi.org/10.7759/cureus.44230(accessed 4 June 2025)

9. Alhamdan MR, Aloudah NM, Alrajhi S. Examining Physicians Approaches to Treating Relatives in Primary Health Care Centres: Insights from a Qualitative study. InHealthCare 2024 Oct 11; Vol 12 (20): 2021 Available from: https://doi.org/10.3390/healthcare12202021 (accessed 4 June 2025)

10 Eastwood GL. When relatives and friends ask physicians for medical advice: ethical, legal, and practical considerations. Journal of general internal medicine. 2009; 24:1333-5.

 11 Beigel F, Mertz M, Salloch S. A systematic review documenting reasons whether physicians should provide treatment to their family and friends. Family Practice. 2024; 41(4):395-403.

12. Beauchamp T and Childress J. Principles of Biomedical Ethics, 1^st edn. New York: Oxford University Press;1977.

13  Hutchinson C, Mc Connell PC. The ethics of treating family members. Current Opinion in Anaesthesiology. 2019 Apr1;32(2):169-73.

14. La Puma J, Priest ER. Is there a doctor in the house? An Analysis of the Practice of Physicians treating their own families. JAMA. 1992 Apr 1;267(13):1810-12.

15 Fromme EK, Farber NJ, Babbott SF. Pickett ME, Beasley BW. What do you do when your loved one is ill? The line between physician and family member. Annals of internal medicine. 2008 Dec 2;1499 110:825-9.

16. Cook JW, Dillmon M, Graff SL, Pentz RD, Srivastava R, Close JL. Caring for Colleagues and Loved Ones with Cancer. American Society of Clinical Oncology. Annual Meeting 2018; 38: 903-908.

17. Geiderman JM, Marco CA, Iserson KV. Emergency physician care of family members, friends, colleagues and self. The American journal of emergency medicine. 2019; 37(5):942-6.

Featured image by Hush Naidoo Jade Photography on Unsplash