Confidentiality

1. Confidentiality

2. Patients reveal sensitive information: -emotional problems - alcohol and drug use - sexual activities • The information disclosed may be of interest to parties outside the medical relationship. • The presumption is that physicians maintain confidentiality

3. Traditionally, ethically, and legally guarded • Physicians are obliged to refrain from divulging information • Take reasonable precautions to ensure that such information is not inappropriately divulged

4. Reasons for confidentiality: • Shows respect for patients. • Has beneficial consequences • Patient • Physicians • Society

5. Benefits to patients: • Prevents harmful consequences to the patients: Stigmatization Discrimination Exploitation • Control access to sensitive personal information

6. Benefits to physician: • Maintain physician-patient relationship • Maintain trust • Treat patient effectively • Abide by law and code of conduct

7. Benefits to society • Treat patients effectively • Prevent spread of diseases to other members of society

8. Code of professional conduct: • Strong tradition in medicine • The Hippocratic Oath states "what I may hear in the course of the treatment Which on no account one must spread abroad, I will keep to myself, holding such things shameful to speak about". • Modern professional codes similarly urge physicians to maintain confidentiality and bases the duty on respect for the autonomy

9. Law • The legal system also hold physicians liable for unwarranted disclosure of medical information.

10. Difficulties maintaining confidentiality: • Professional indiscretions: • Confidentiality has been treated rather carelessly in modern medical care. • Speak about patients in public places: • hospital elevators and cafeteria. • Cell phone conversations

11. Difficulties maintaining confidentiality: • Medical records: • Records may not be well secured • Accessible to many persons • attending physicians • house staff • Students • Consultants • Nurses • social workers • Pharmacists • Secretaries • medical records personnel • insurance company employees • Quality care reviewers

12. Difficulties maintaining confidentiality: • Computerized records: • enhances statistical information • facilitates administrative tasks • availability of medical record information to interested third parties • many people have access to medical records • information can be obtained from any computer station and information on a large number of patients can be accessed at once

13. Difficulties maintaining confidentiality: • Other new communication technologies: • Fax • e-mail

14. Waivers of confidentiality: • Patients commonly give physicians permission to disclose information about their condition to others e.g. insurance companies. • Insurers often require clinical information before they reimburse physicians or hospitals. • Patients may not appreciate that signing a general releases allows the insurance company to disseminate the information further. • Insurance companies generally place patient’s diagnosis in a computer database that is accessible to other insurance companies or to employers without further permission from the patients.

15. Case 1: A 32 years old woman is admitted to the hospital after a serious automobile accident. She is disoriented and confused. The patient's sister requests that the patient's husband not be given any information. The patient has previously told the physician about her hostile divorce proceedings. The husband, however, learns that she is hospitalized and inquires about her condition.

16. Case 2: A 61 years old man is diagnosed with metastatic cancer of the prostate. He refuses hormonal therapy and chemotherapy. He instructs his physician not to inform his wife and says he does not intend to tell her himself. The next day, the wife calls to inquire about her husband's health.

17. Case 5: A 35 years old accountant reveals to his physician that he had a positive test for HIV antibodies at an anonymous testing center. He asks his physician not to disclose the test results to anyone, because he is concerned about losing his job and health insurance. His physician encourages him to notify his wife, so that she can be tested. After several discussions, the patient continues to refuse to notify his wife or allow others to do so. HE declares, "If she finds out, it would destroy our marriage". Should the physician notify the wife despite the patient's objections?

18. Case 6: A 32 years old man diagnosed pre-symptomatically with Huntington's disease. This is an autosomal dominant genetic disease (50% chance of transmitting the gene and the disease to offspring). He tells his physician that he does not want his wife, whom he recently married, to know. The physician knows that the wife is eager to have children.

19. Case 7: A 32 years old male is diagnosed with bacterial meningitis. After the physician explained his diagnosis to him, the risks and benefits, the patient refused to be treated for his illness and insisted on going home.

20. Case 8: A nephrology fellow working in a dialysis unit is positive for Hepatitis C antigens. He resists any restriction of his professional activities. He approaches another physician, an infectious control specialist, for advice. After being advised to tell the relevant parties, including the hospital infection control team, he states that he does not intend to disclose his diagnosis. He insists on confidentiality. Should the infectious disease specialist take steps to have the nephrology fellow's clinical activities restricted?

21. Case 9: A 45 years old woman with a history of idiopathic seizures is diligent about taking anti-seizure medication. Her last major seizure was 16 months ago. To qualify for a driver's license, the law requires a physician's declaration that the patient has been free from seizures for 24 months. She pleads with her doctor for this certification because she need to drive to continue her job.

22. Case 10: A 28 years old man who has been under a physician's care for severe peptic ulcer impresses the doctor as somewhat bizarre in attitude and behavior. The doctor suspects that his patient suffers from a psychiatric disorder and asks him whether he is seeing a psychiatrist. The patient calmly responds that he was once under treatment for schizophrenia but has been well for years. Then, in the course of an office visit, he casually states that he would like to see all politician dead and was going to attend a political rally "to see what he could do". Should the physician report the patient?

23. Case 11: A woman arrives at the emergency department with serious contusions on the right side of her face and two teeth missing. Her nose appears to be broken. Her husband accompanies her. He explains that she tripped on the carpet and fell down a flight of stairs. She affirms his story. The emergency resident suspects spousal abuse. He does not know the couple, however, and judges by their distress and manner that they appear to be respectable citizens.

24. Overriding confidentiality • To protect third parties • To protect patient him/herself

25. To protect third parties: • Infectious diseases • Impaired drivers • Injuries caused by weapons and crimes • Psychiatric patients

26. To protect third parties: • Confidentiality can be overridden is several ways. • Physicians need to distinguish between: • reporting to public officials • partner notification by public health officials • direct warnings to third parties at risk

27. Justification for overriding confidentiality:

28. Justifications include: In general exceptions to confidentiality are warranted when all the following conditions are met: • The potential harm to identifiable third parties is serious and greater than the harm to the index case resulting from overriding confidentiality • The likelihood of harm is high • There are no less invasive alternative means for warning or protecting those at risk

29. Justifications include: • Breaching confidentiality allows the person at risk to take steps to prevent harm • Harms to the patient resulting from the breach of confidentiality are minimized and acceptable. • Disclosure should be limited to information essential for the intended purpose, and only those persons with a need to know should receive information

30. Overriding confidentiality to protect patients themselves: • Child abuse • Elder abuse • Domestic violence

31. Questions?