Changing practice on confidentiality: further points for discussion

In the March 1982 issue of the Journal Dr Pheby, a community health doctor, was one of several writers to discuss medical confidentiality. Dr Pheby urged doctors to minimise subjective and judgmental comments in medical records and to make clear when their assessments were speculative. He also urged `vigorous reappraisal of the extent to which information about a patient needs to be circulated' to members of other disciplines, for instance, in child health practice. If doctors did not take such steps themselves legal changes might well be imposed upon them, giving patients the right of access to their medical records and perhaps making breach of medical confidentiality a criminal offence.

Mr Jacob, a lawyer, commenting on the papers by Dr Pheby and Mr Kenny, a health administrator, argued that increased legal intervention in medical ethics could quite possibly actually erode traditional medical ethical standards of confidentiality based on peer review and `the ethic of virtue'.

     

The utilitarian argument for medical confidentiality: a pilot study of patients' views

OBJECTIVES: To develop and pilot a questionnaire based assessment of the importance patients place on medical confidentiality, whether they support disclosure of confidential information to protect third parties, and whether they consider that this would impair full disclosure in medical consultations. DESIGN: Questionnaire administered to 30 consecutive patients attending a GP surgery. RESULTS: Overall patients valued confidentiality, felt that other patients might be deterred from seeking treatment if it were not guaranteed, but did not think that they would withhold information for this reason themselves. CONCLUSIONS: When presented with brief details of five clinical situations in which a breach of confidentiality might be considered, a clear majority of subjects believed that doctors should disclose information in two of the situations, but subjects were not confident that doctors would do so. In three situations, about half felt that disclosure was justified--these included the only scenario in which disclosure was clearly mandated by statute. There was little change in patients' general attitude to confidentiality after considering the scenarios. However, the views expressed were often inconsistent with responses to the clinical scenarios, suggesting that complex opinions were not accurately reflected in the responses. The format of the questionnaire has been amended, and the study will be repeated with other groups of patients.     

HIV, confidentiality and 'a delicate balance': a reply to Leone Ridsdale.

The passing on of information to GPs by genito-urinary doctors is to be encouraged but is not always possible and ultimately the patient's wishes and confidentiality must be respected if sexually transmitted diseases and HIV infection are to be controlled. Infected health-care workers should seek counselling and medical support and clear guidelines from professional organisations which are in existence. However, they will only do so if strict confidentiality is maintained and assurance about future employment can be given.     

AIDS and medical confidentiality

In summary, I have argued that the arguments offered or hinted at in favour of doctors' breaking medical confidentiality by passing on information about their patients' HIV state to others, including other doctors, when this is against the patient's considered wishes are generally unconvincing. Although in highly exceptional cases there may be justifications for overriding confidentiality, the requirement of medical confidentiality is a very strong, though not absolute, obligation. Patients, their contacts, doctors and their staff, and the common good are most likely to be best served if that tradition continues to be honoured.     

A qualitative study of women's views on medical confidentiality

CONTEXT: The need to reinvigorate medical confidentiality protections is recognised as an important objective in building patient trust necessary for successful health outcomes. Little is known about patient understanding and expectations from medical confidentiality. OBJECTIVE: To identify and describe patient views of medical confidentiality and to assess provisionally the range of these views. DESIGN: Qualitative study using indepth, open ended face-to-face interviews. SETTING: Southeastern Pennsylvania and southern New Jersey, USA. PARTICIPANTS: A total of 85 women interviewed at two clinical sites and three community/research centres. MAIN OUTCOME MEASURES: Subjects' understanding of medical confidentiality, beliefs about the handling of confidential information and concerns influencing disclosure of information to doctors. RESULTS: The subjects defined medical confidentiality as the expectation that something done or said would be kept "private" but differed on what information was confidential and the basis and methods for protecting information. Some considered all medical information as confidential and thought confidentiality protections functioned to limit its circulation to medical uses and reimbursement needs. Others defined only sensitive or potentially stigmatising information as confidential. Many of these also defined medical confidentiality as a strict limit prohibiting information release, although some noted that specific permission or urgent need could override this limit. CONCLUSIONS: Patients share a basic understanding of confidentiality as protection of information, but some might have expectations that are likely not met by current practice nor anticipated by doctors. Doctors should recognise that patients might have their own medical confidentiality models. They should address divergences from current practice and provide support to those who face emotional or practical obstacles to self-revelation.     

Social media and the medical profession

Use of social media by doctors and medical students is common and growing. Although professional standards and codes of ethics that govern the behaviour of medical practitioners in Australia and New Zealand do not currently encompass social media, these codes need to evolve, because professional standards continue to apply in this setting. Inappropriate use of social media can result in harm to patients and the profession, including breaches of confidentiality, defamation of colleagues or employers, and violation of doctor-patient boundaries. The professional integrity of doctors and medical students can also be damaged through problematic interprofessional online relationships, and unintended exposure of personal information to the public, employers or universities. Doctors need to exercise extreme care in their use of social media to ensure they maintain professional standards.     

Professional ethics—for whose benefit?

In a wide ranging paper the author, a barrister, considers medical ethics in the context of divided loyalties, particularly those of a doctor employed by the National Health Service and those of doctors in occupational medicine. He argues for more specific professional codes of medical ethics, especially in relation to the need to obtain patients' explicit consent before medical details are transmitted to third parties. On the thorny question of when, if ever, can the good of society override the doctor's special duty to his patient of confidentiality, he urges medical organisations to be more explicit at least on how members can set about resolving such dilemmas - mere assertion that a problem exists and that individual doctors must resolve it according to their consciences is not good enough, he says. Extolling honesty and openness as fundamental values he ends by suggesting that part of a binding code of medical ethics might be a requirement that doctors display in their waiting rooms information about their personal moral stances concerning major dilemmas of medical ethics. The paper was given as the Lucas lecture under the aegis of the Royal College of Physicians' Faculty of Occupational Medicine, in whose journal it is also published.     

Consent, compulsion and confidentiality in relation to testing for HIV infection: the views of WA doctors

A survey was undertaken of all of the consultant staff members of Perth's major teaching hospitals together with all the fellows of The Royal Australian College of General Practitioners in Western Australia in order to define their views on the issues of informed consent, compulsion in relation to surgery, and confidentiality in a particular circumstance, when testing for infection with the human immunodeficiency virus (HIV). Of the 701 individuals surveyed, 548 (78.2%) responded. Of these, 74.3% considered that it was not always necessary to gain informed consent, 22.0% believed that it was always necessary to do so, while 2.3% were undecided. General practitioners (38.4%) were more likely to think it necessary to obtain consent than were hospital consultants (19.0%), but otherwise the field of specialty had little effect on opinion. Of the respondents, 39.0% believed that testing before elective surgery is mandatory for all patients, while 53.0% considered that it should be compulsory in high-risk groups. Similar views were held about compulsory HIV antibody testing after emergency surgery. Similar responses were obtained from all specialty groups. When asked about whether they would tell a sexual partner of a patient's HIV status when the patient refused, 10.5% of doctors stated they would never advise the partner, 24.7% of doctors would on some occasions, 41.0% of doctors would tell a partner, and 23.8% always were undecided. Many individuals commented that they failed to see why HIV infection was being treated differently from other serious diseases. We have found that the majority opinion of the most senior members of the medical profession is that specific, informed consent should not always be required, that there is great support for compulsory testing, and that confidentiality may be broken under certain circumstances. These views must be recognized by administrators and legislators when framing measures to control this infection.     

Community versus individual benefit

Australian law embodies a "communitarian" conception of the doctor's responsibility to respect the confidentiality of the doctor-patient relationship. This implies that respect for confidentiality sits alongside two other responsibilities: proper care for the patient's general wellbeing and proper attention to the safety of the community. Most jurisdictions now require drivers to advise their local driver-licensing authority of any permanent or long-term injury or illness that affects their ability to drive safely. Some jurisdictions require doctors to inform the driver-licensing authority about patients whose medical condition may impair their driving to the extent that they are likely to endanger the public. If you can not persuade a patient to inform the driver-licensing authority of the need for an assessment of his or her ability to drive safely, then you should inform the relevant authorities yourself.     

Psychiatric disorders and fitness to drive

OBJECTIVE: In Switzerland, as in some other European countries, medical doctors may breach patient confidentiality and report to police authorities any patient who seems prone to automobile accidents or traffic violations. The aim of this study was to see if those patients reported to authorities actually represent a higher risk than drivers not reported to the police. DESIGN: This study was designed following a case-control study comparing the characteristics of a group of psychiatric patients who were reported to authorities for preventive purposes, with the characteristics of another group of people who had disorders that were noticed at the time of an accident or traffic violation. RESULTS: The results show that medical doctors tended to report male patients, patients with a low level of education, and patients with a severe psychiatric background. The subjects of the control group, who had often been involved in accidents or committed traffic violations in the past, did not possess these characteristics. CONCLUSIONS: The breach of medical confidentiality by doctors in reporting to authorities patients who are allegedly at risk is ethically questionable as long as the evaluation of driving performance does not rely on objective bases.     

Doctors with AIDS and the "News of the World"

A detailed account is given of a 1987 case in which a British newspaper was found in contempt of court for publishing an article based on confidential information about two doctors undergoing tretment for AIDS. The health authority treating the doctors had won an injunction restraining the newspaper from using any information from the doctors' medical records, based on the law of confidence which holds employees to a duty not to disclose confidential information acquired in the course of employment, unless it is in the public interest that it be disclosed. The court relied on testimony of medical experts that the risk to patients from general practitioners with AIDS could be reduced, by training and education, to nonexistence, and emphasized that confidentiality is of paramount importance to AIDS patients and therefore is in the public interest.     

HIV infection and AIDS: the ethics of medical confidentiality.

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients.     

The mandatory sentence and Section 2.

Sentencing in homicide depends on how psychiatrists view the issues of Section 2. In most killings that do not involve clear-cut mental disorder, strong emotions and stress play a part. Both can be cited in aid of diminished responsibility. If doctors cite them, however tentatively, it becomes feasible for the court to review any mitigating factors and to choose an appropriate penalty. Otherwise, the mandatory penalty is imposed. Thus doctors, by opining not on the medical but on the legal and moral aspects of Section 2, decide who shall automatically get a life sentence and who shall not. Anomaly and injustice are the results. They would be remedied by the abolition of the mandatory sentence for murder.     

Rational non-interventional paternalism: why doctors ought to make judgments of what is best for their patients.

This paper argues that doctors ought to make all things considered value judgments about what is best for their patients. It illustrates some of the shortcomings of the model of doctor as 'fact-provider'. The 'fact-provider' model fails to take account of the fact that practising medicine necessarily involves making value judgments; that medical practice is a moral practice and requires that doctors reflect on what ought to be done, and that patients can make choices which fail to express their autonomy and which are based on mistaken judgments of value. If doctors are properly to respect patient autonomy and to function as moral agents, they must make evaluations of what their patients ought to do, all things considered. This paper argues for 'rational, non-interventional paternalism'. This is a practice in which doctors form conceptions of what is best for their patients and argue rationally with them. It differs from old-style paternalism in that it is not committed to doing what is best.     

论作为"德性"的医学职业道德

规范伦理学是一种重要的道德理论形式,当前的医学伦理学体系普遍以规范伦理学作为基础.但是,这种道德理论在有效指导医学职业道德实践的同时,也显出一定的局限性.这种局限性主要表现为道德规范间的内部冲突性和道德要求的绝对性,这使医务人员的医疗实践经常处于两难之中,并会影响到他们的职业热情.德性伦理学以其不同的学术视野为我们完善医学伦理学体系提供了另外的理论空间.德性精神的内在统一性、稳定性和灵活性使其成为规范伦理的有益补充.如果我们想使一种以"仁爱"和"正义"精神为核心的医学德性在医务人员身上得到普遍化的实现,就需要我们深入反思我们的医学职业道德教育形式并努力建设一个良好的外部环境.相信在医学德性伦理得到普遍实现的时候,我国医疗领域的职业道德状况将得到很大改善.     

Confidentiality: the confusion continues

The author, a regional health authority administrator, argues that `ownership' is a side issue in legal and moral arguments over confidentiality of medical records. Nor is it practicable, he argues, for doctors alone to control all access to the medical records. He proposes the principle of `custodianship' of confidential information, to be accepted by an institution as a whole, as a possible way of resolving the problem. In commentaries on this and the following article an academic lawyer and a practising physician respond.     

Why patients should keep their own records.

Too many people now have access to confidential medical information. Patients are becoming justifiably wary and the doctor-patient relationship is deteriorating. We can avert the developing crisis by allowing patients to keep their own medical records at home. This will ensure that confidentiality is respected and that patients continue to trust their doctors.     

论医学人文精神与医患关系的改善

古人云:"医乃仁术",医生被誉为"仁爱之士".然而,随着现代医学技术的迅速发展,医患关系却日趋紧张.其原因主要有医疗体制问题、国家对医疗卫生事业的投资问题,但也有医务人员自身的原因.由于部分医生人文素质的欠缺,使得他们不善于与病人沟通,医患之间的诚信度一降再降,医患关系日趋紧张.因此,面对身体和心理上都受到打击的患者,医务人员除了运用医学技术为患者减轻或解除病痛,还需要不断地提高自身的人文素质,善于与患者沟通,取得他们的信任,并给患者多一点的人文关怀.     

Confidentiality and the law.

Codes of medical ethics issued by professional organizations typically contain statements affirming the importance of confidentiality between patients and health-care practitioners. Seldom, however, is the confidentiality obligation depicted as absolute. Instead, exceptions are noted, the most common of which is that health-care professionals are justified in breaching the confidence of a patient if required by law to do so. Reasons that might be given to support this exception are critically discussed in this paper. The conclusion argued for is that this is not a legitimate exception to the confidentiality rule.