Confidentiality: Applying Ethical Frameworks in Practice

In the medical world, one of the most important agreements that are made between the caregiver and the patient is that of confidentiality.  However, from time to time, a caregiver will come across a scenario in which medical information might be a concern for others to the point that it needs to be shared.  It is in these times that the caregiver faces an ethical dilemma: should they breach the confidentiality of their patient in order to provide either better health care to that patient or warn the general public about a potential health issue, or should they keep their promise even though it may have adverse effects on both the patient and the community at large? Also, what is the ethical responsibility of a nurse? Finding the answer to this question is an extremely difficult endeavor as specific situations can largely dictate the need, or lack thereof, to divulge such information.  The caregiver should, therefore, only breach the patient’s confidentiality if it will directly result in saving the patient’s or someone else’s life.

It is of the utmost importance to understand to what extent and why patient confidentiality is crucial for the medical community. The Hippocratic oath clearly states, “all that may come to my knowledge in the exercise of my profession…I will keep secret and will never reveal” and, “ I will respect the secrets which are confided in me, even after the patient has died” (Boyd, 1992, p. 173).  Confidentiality is critical because it allows for trust between a doctor and a patient to be built and maintained.  This allows a patient to reveal some of the most sensitive medical histories about himself or herself, which is often necessary for accurate diagnosis and treatment.  If the caregiver clearly violates this confidentiality, patients will lose faith in the health system and not truthfully reveal the full extent of their medical history which could lead to incorrect diagnoses, inaccurate interpretation of symptoms, and, generally, the mistreatment and wrongful allocations of medical resources on patients.  It is for these reasons why confidentiality must be taken so seriously and, if at all possible, not breached.  However, there are certain cases where the line between withholding and divulging sensitive data becomes blurred. 

For certain cases, there exists a need for the release of some of the more sensitive data that can be seen as a breach of confidentiality.  Cases such as this are exemplified by the example from NBC’s ER.  In the show, a 14-year-old patient named Andrea had a medical test performed to determine if she had HPV, and it was revealed to her that not only did she have HPV but that she had cervical cancer (Nathanson, 2000).  She also informed the caregiver that she had engaged in ‘sex parties’ with her fellow classmates, which was the likely cause of her contraction of HPV and, subsequently, cervical cancer.  Though the caregiver had sworn to Andrea that she would not involve her parents in the knowledge that Andrea had been tested, revealing that she was sexually active, the caregiver was forced to reexamine the statements when she discovered that Andrea has been diagnosed with a serious medical disease (Nathanson, 2000).  Ultimately, the caregiver is forced to break the patient’s confidentiality by informing her parents about her condition.  This may be seen to some as a break in confidentiality and unacceptable, however, this is one of the rare exceptions to the idea that caregivers will periodically face.

Another case of the grey area that exists in patient confidentiality is the sharing of medical records between caregivers.  Take the case presented in the Australian Medical Journal.  In the case provided, a patient, labeled Ms. Z, was concerned about her new GP having access to her previously run tests by accessing them from her previous physician.  From her own history, she was concerned and untrusting of individuals being able to know about her medical history and having the ability to trace her (Braunack-Mayer & Mulligan, 2003).  The prevailing question is: should a patient be upset at this data sharing?  

In cases such as these, there exists a distinct element of an ethical dilemma that must be addressed.  In the case such as with NBC’s ER, it is apparent that the patient confidentiality had to be breached because it was the only means by which the caregivers could ensure that the patient would receive the proper care for her medical condition.  Even though they promised her discretion, if they had acted on that sentiment, the patient would have been placed in much more dangerous circumstance, and, being that she was a minor, the hospital system could have faced legal repercussions.  This is an ethical conundrum for a nurse. In the case of Ms. Z, it is apparent that all that needed to be done was to simply ask her if she was all right with the sharing of her data and to draw note to how doing so would save her time and money as it would dramatically decrease the time she had to spend in the clinic’s care.  It is, therefore, important to realize, “actions that are taken should consider what is healthiest for all parties involved” (Melroe, 1990, p. 58).  The patient may have to have their confidentiality violated, but only if it is in the interest of their overall health.

In terms of a committee examining the places where a breach of confidentiality is acceptable and where it is not and determining guidelines to set down for caregivers to follow, the outcome is unclear on the effectiveness.  The only fair option is to take each case on a case-by-case scenario and try to determine what is best for both the patient’s health and the safety of the community as a whole. If divulging information because of this will provide a safer environment for all parties, then it seems that the breach of confidentiality is warranted.  If not, the caregiver must respect the patient’s decision to withhold such medical conditions and not violate their confidentiality.             

References

Boyd, K. M. (1992). Hiv infection and aids: the ethics of medical confidentiality. Journal of Medical Ethics, 18(4), 173-179. Retrieved from http://jme.bmj.com/content/18/4/173.full.pdf

Braunack-Mayer, A. J., & Mulligan, E. C. (2003). Sharing patient information between professionals: Confidentiality and ethics. Medical Journal of Australia, 178(6), 277-279. Retrieved from https://www.mja.com.au/journal/2003/178/6/sharing-patient-information-between-professionals-confidentiality-and-ethics

Melroe, N. (1900). 'Duty to war' vs. 'patient confidentiality:’ The ethical dilemmas in care for HIV-infected clients. Nurse Pract, 15(2), 58-65. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2308712

Nathanson, P. G. (2000). Bioethics on nbc's er: Betraying trust or providing good care? When is it okay to break confidentiality? Bioethics. Retrieved from http://web.archive.org/web/20110706061843/http://www.bioethics.net/articles.php?viewCat=7&articleId=133