Ontario Medical Association (OMA)

Response in PDF format. 

Executive Summary
I support the College's commitment to preventing exploitation and harm in physician-patient relationships. However, I am concerned that overly broad boundary restrictions infantilize adult patients, particularly harm marginalized communities, and impose unnecessary barriers on consensual relationships between adults. I urge the College to adopt narrow, evidence-based standards that protect against genuine exploitation while respecting patient autonomy and the realities of practice in diverse communities.
 

Core Principles

Any boundaries policy must balance two legitimate concerns:

1. Preventing exploitation: Physicians hold positions of trust and authority. Policies must prevent abuse of that power.

2. Respecting patient autonomy: Adult patients are capable of making informed decisions about their relationships, including with their physicians.

    

   Current approaches often prioritize the first concern while completely disregarding the second. This is paternalistic and harmful.
    

Patient Autonomy and Anti-Paternalism
Medical paternalism—the practice of making decisions "for the patient's own good" without meaningful input from the patient—is increasingly recognized as unethical. Yet boundary policies that categorically prohibit certain relationships treat adult patients as incapable of consent.

This approach is particularly harmful to:
 

• Women patients: Blanket prohibitions on romantic relationships with former patients perpetuate patriarchal assumptions that women cannot navigate power dynamics or make informed decisions about their romantic lives.

• Patients from marginalized communities: Many marginalized patients already experience medical paternalism. Indigenous patients, racialized communities, LGBTQ+ individuals, and persons with disabilities report that medical systems frequently dismiss their agency and autonomy. Boundary policies that presume patients cannot consent to relationships compound this systemic disrespect.
  Rural and remote communities: In small communities, strict separation between physician and patient roles is often impossible and undesirable. Physicians are members of their communities, not external authorities imposed upon them.
  
  Recommendation: The College must distinguish between relationships that involve active exploitation and relationships that involve two consenting adults navigating complex circumstances. Policies should protect the former without criminalizing the latter.

Relationships with Former Patients
Current approaches often impose permanent or multi-year bans on romantic or sexual relationships with former patients. These restrictions are excessive and discriminatory.

Problems with Permanent Bans:
Discriminatory impact on rural physicians: In small communities, most potential romantic partners may be former patients. Permanent bans effectively prohibit these physicians from forming romantic relationships within their communities, forcing them to choose between their profession and their personal lives.
No evidence of ongoing harm: Once a therapeutic relationship has ended and sufficient time has passed, the power dynamic that justified restrictions no longer exists. A blanket prohibition assumes permanent vulnerability, which contradicts principles of patient recovery and autonomy.
Vague and arbitrary timelines: Policies that impose waiting periods (e.g., one year, two years) are inherently arbitrary. They do not account for:
 

• The nature of the original therapeutic relationship (single consultation vs. long-term care)

• The patient's circumstances (acute crisis vs. routine care)

• The patient's own assessment of the relationship

Inconsistent with other professional standards: Other professionals in positions of trust (lawyers, therapists in some jurisdictions, professors) recognize that relationships with former clients may be appropriate after the professional relationship ends. Medicine should not be uniquely restrictive without evidence justifying that distinction.

Alternative Approach:
Rather than categorical prohibitions, the College should:

• Prohibit relationships with former patients where there is evidence of:

  • Active dependency (patient still receiving care or vulnerable)

  • Exploitation during the therapeutic relationship

  • Coercion or grooming

     

     

• Permit relationships with former patients where:

  • The therapeutic relationship has genuinely ended

  • The patient initiated or clearly consented to the relationship

  • There is no evidence of exploitation or ongoing vulnerability

  • The physician can demonstrate the relationship does not compromise professional judgment

This approach trusts patients to assess their own circumstances while providing clear standards against exploitation.

Non-Sexual Boundary Issues
The draft policy addresses non-sexual boundaries including gifts, financial relationships, and social interactions. I support transparency and accountability in these areas but caution against overly restrictive rules.

Appropriate Standards:
Disclosure requirements: Physicians should disclose financial relationships and potential conflicts of interest to patients.
Prohibition of exploitation: Physicians must not use their position to pressure patients into financial arrangements, business relationships, or gift-giving that benefits the physician.
Cultural competence: Boundary expectations must account for cultural differences in gift-giving, social relationships, and concepts of professional distance.
 

Inappropriate Standards:
 

Blanket prohibitions on gifts: In many cultures, gift-giving is an essential expression of gratitude and respect. Prohibiting all gifts disrespects these cultural norms and creates barriers to culturally safe care.
Restrictions on social media interaction: Adults are capable of managing their social media relationships. Prohibiting physicians from interacting with patients on social media treats both parties as incapable of maintaining appropriate boundaries in modern communication contexts.
Prohibitions on dual relationships in small communities: In rural and remote areas, physicians are community members. They may serve on local boards, attend community events, and have social relationships that overlap with professional relationships. Policies must recognize these realities rather than imposing urban assumptions about professional separation.
 

Recommendation: Non-sexual boundary rules should focus on preventing exploitation and ensuring transparency, not on enforcing arbitrary separation between physicians and patients in all contexts.
 

Trauma-Informed Care and Boundary Policies
 

The consultation materials indicate that updates are guided by principles of trauma-informed care. I support trauma-informed approaches but caution that these principles must not be weaponized to justify paternalism.
 

Trauma-informed care includes:
 

• Recognizing the prevalence of trauma

• Creating safety and trust

• Supporting patient choice and autonomy

• Empowering patients
   

Trauma-informed care does NOT mean:
 

• Presuming all patients are permanently vulnerable

• Removing patient agency in the name of protection

• Imposing restrictions that survivors themselves may not want

Many trauma survivors report that medical paternalism—being told what they can and cannot consent to—replicates the loss of autonomy they experienced during trauma. A truly trauma-informed approach centers survivor voices and respects their capacity to make decisions about their own relationships.

Recommendation: Trauma-informed care must enhance patient autonomy, not undermine it. Policies should provide options, support, and transparency—not blanket prohibitions.

Mandatory Reporting and Chilling Effects
If the policy includes mandatory reporting requirements for boundary concerns, I urge extreme caution. Mandatory reporting creates significant risks:
 

Chilling effect on patient disclosure: Patients may avoid disclosing relationship dynamics to their physicians if they fear mandatory reporting will result in investigations, public exposure, or unwanted interventions.
Weaponization of reporting: Mandatory reporting can be misused by third parties (family members, estranged partners) to interfere in relationships they disapprove of, even when there is no exploitation.
Disproportionate impact on marginalized physicians: Physicians from racialized communities, LGBTQ+ physicians, and those practicing in small communities may face disproportionate scrutiny and reporting based on cultural misunderstandings or bias.
 

Recommendation: 

Mandatory reporting should be limited to cases where there is clear evidence of:
 

• Current exploitation

• Coercion

• Abuse of a vulnerable patient

Reports based on speculation, "concern," or disapproval of consensual relationships should not be mandated.
Recommendations Summary
The College should adopt a boundaries policy that:
Distinguishes exploitation from autonomy: Prohibit relationships involving coercion, exploitation, or abuse. Permit relationships between consenting adults where no exploitation has occurred.
Ends permanent bans on former patient relationships: Replace categorical prohibitions with evidence-based assessments of whether exploitation occurred or ongoing vulnerability exists.
Respects cultural diversity: Acknowledge that boundary norms vary across cultures and communities. Policies must not impose dominant cultural assumptions as universal standards.
Centers patient autonomy: Policies must not presume adult patients are incapable of making decisions about their relationships.
Limits mandatory reporting: Restrict mandatory reporting to clear cases of exploitation, not to consensual relationships that make observers uncomfortable.
Accounts for small community realities: Recognize that rigid separation between professional and personal roles is often impossible and undesirable in rural, remote, and tight-knit communities.
Conclusion
The College's mandate is to protect the public from harm, not to micromanage the personal lives of physicians and patients. A boundaries policy grounded in evidence, respect for autonomy, and cultural humility can achieve the first goal without overreaching into the second.
I urge the College to trust adult patients to make informed decisions about their relationships and to focus regulatory efforts on preventing genuine exploitation rather than policing all relationships that might create the appearance of impropriety.
A narrow, evidence-based approach will better serve both patient safety and patient autonomy than the current trajectory toward increasingly restrictive paternalism.

Draft Policy lines 24, 25 state the definition of doctor / patient relationship extends for one year from date of last medical care (prescription, other).  I assume this is accurate and is new information for me.

Discussion mentioned trauma informed care should perhaps be universally considered as a potentially relevant risk in the history among all patients.  I found that potentially valuable for consideration.

Note:  With respect to what is trauma - trauma informed care might be considered beyond sexual trauma.  I’ve been power of attorney for two family members, one in cardiac ICU in Hamilton (respirator for weeks) then recovered and one in Guelph (acute bacterial infection - no respirator).  The post ICU memories and triggers of her sudden serious illness remain.  Her professional medical, nursing, respiratory and care were quite good.  Other examples of trauma might include traffic accident, complicated childbirth and more.

My usual reading and interests include reliable media which very recently has featured a small group of people who have transitioned (breasts removed) who later request de-transition surgery.  An article referenced physician refusal of this request by patients.  Perhaps for consideration and boundaries if this request might be presented to the physician.  I do not have family members or friends who have transitioned.  This information is emerging in reliable media. 

The word “must” should be replaced by “should offer” on this revision.
By using the word “must”, someone who fails to make the offer has committed sexual abuse, and potentially faces mandatory revocation. This would be very harsh.

In general, I have a concern that the term “sexual abuse” of any sort, as defined by the policy is treated the same way when it comes to sanctions: mandatory revocation for five years minimum, with no mitigating circumstances or consideration of the type of “sexual abuse”. It is similar to the problematic application of mandatory minimum sentencing in criminal matters. If there were more nuance in this area, perhaps using the word “must offer” would be more acceptable.

Thanks for the offer to provide input.

The main concern that I have was the proscribing against sexual relations with a relative of a patient.  The policy needs to be more specific - i.e. parent, child, brother - does it extend to in-laws cousins aunts uncles.    Better definition of who should be excluded -it should be made chrystal clear.

Professional Association of Residents of Ontario (PARO)

Dear CPSO Policy Department,

Thank you for the invitation to provide feedback on Maintaining Appropriate Boundaries CPSO draft policy. We found the draft policy and advice to physicians to be very well written and very much reflective of the College’s mandate to protect patients. We have reviewed the document and do have some suggestions.

Guidance on digital and virtual care boundaries in this policy is missing, such as the expectations around texting, social media, virtual photos or use of patient messaging platforms like MyChart and virtual appointments. As virtual care is a large part of the healthcare system now it would be important to include information regarding this in the policy.

Also missing in the policy are clear expectations for physicians supervising learners and the boundary standards in these situations, for the physicians, learner and patient.

Once again, we truly appreciate being included in the CPSO's consultative process.