Confidentiality

1. Confidentiality Modes of Ethical Reasoning

2. Confidentiality • One of few modern health care ethics precepts included in Hippocratic Oath • Everyone says it is serious • No one says it is absolute

3. Why Is Confidentiality Important? • What if no bad consequences follow from revealing private information? • Most people would feel wronged even if no bad consequences • Suggests moral reasoning is more Kantian than utilitarian (respect for persons)

4. Confidentiality and Autonomy • How is violation of confidentiality a threat to personal autonomy? • Control over intimate relationships

5. Most distant Most intimate Me

6. Most distant Most intimate Choose freely to disclose personal information Me

7. Most distant Most intimate Me Choose to withhold personal information

8. When to Override Confidentiality? • High risk of serious harm to identifiable person • No alternative way to avoid harm • One takes steps available to minimize harm to patient from disclosure

9. Overriding Confidentiality • To prevent harm to a third party (see previous justifications) • To prevent harm to the patient (same criteria as justifying paternalism)

10. Reporting Law: A Special Case • Law is publicly known • We have obligations to know what the law is • Therefore can argue that patient has implicitly given consent if now seeking medical care under those circumstances • How valid a justification?

11. Approaches to Ethical Reasoning • Principles • Cases • Either-or or both-and?

12. Abstract principles Concrete specific judgments PRINCIPLES CASES

13. Principles • Ethical wisdom lies in a small number of concise, abstract principles • From principles can deduce what to do in a given case • Case “anecdotes” are merely illustrative of the correct application of principles

14. Cases (Casuistry) • Ethical wisdom consists of detailed, nuanced, concrete judgments about specific cases • Often uses maxims or rules but these are general organizing concepts, not infallible sources of ethical insight • Often a rule or maxim creates a line of cases

15. The “Truth” Line of Cases • Maxim: Don’t lie • Paradigm case: George W. and the cherry tree • “Line of cases”: Each new case differs just a little more from the paradigm case; as one gets farther away a wider variety of other ethical considerations compete with the maxim

16. Difficult Cases • Kant: Do you tell the truth to the homicidal lunatic who asks which way your friend went? • At intersection of two lines of cases-- “Don’t lie” and “Protect lives” maxims

17. Reasoning About Cases • Differences: how two cases which at first glance seem identical actually have features requiring different ethical analyses or actions • Analogy: how two cases which at first seem quite different actually have common features which may point to an ethical resolution

18. Abstract principles REFLECTIVE EQUILIBRIUM Concrete specific judgments

19. Reflective Equilibrium • Look for best overall “fit” • Reason both from cases to principles and from principles to cases • Sometimes a specific case judgment will seem better “grounded,” other times a principle will • Be willing to revise ethical judgments based on new ideas and insights