Understanding Medical Confidentiality and Ethics

 
Confidentiality
 
Prof. Jasim N. Al-Asadi
2018-2019
 
Learning objectives
 
1. To know the definition of confidentiality and its
basic rules
2. To Identify which information is confidential
3. To describe when confidential information may
be disclosed
4. To describe how best to document disclosures of
confidential information
4.  To Apply their knowledge to synthesize possible
approaches to 
solve
 the problems associated with
breaking confidentiality
 
Confidentiality
 
The doctor patient relation ship is an
extremely confidential one
 
All information that the doctor has acquired
professionally should be kept strictly
confidential
 
(Professional secrecy)
 
Breach of this duty can lead to a civil law suit
or criminal defamation if done intentionally
 
Divulging such information to a third party
(e.g., insurance company or employer) should
be done with consent only
 
H
i
p
p
o
c
r
a
t
i
c
 
O
a
t
h
 
“Whatever, in connection with my
professional practice, or not in connection
with it, I see or hear, in the life of men, which
ought not to be spoken of abroad, I will not
divulge, as reckoning that all such should be
kept secret”
 
The declaration of Geneva of 1948
 
“I will respect secrets confided in me, even
after the patient has died”
 
The international code of Medical
Ethics amended in Venice in 1983
 
“A physician shall respect the rights of patients,
colleagues and of other health professionals and
shall safeguard patient confidences”
“A physician shall preserve absolute confidentiality
on all he knows about his patient even after the
patient is dead”
 
WHO guide lines on Medical Confidentiality
 
All information must be kept confidential
Information can only be disclosed if the patient gives
explicit consent, or if the law specifically provides
Consent may be presumed where disclosure is to
other health care providers involved in that patient’s
treatment
 
All identifiable patient data must be protected
 
Medical interventions may only be carried out
when there is a proper respect shown to the
privacy of the patient. This means that the only
persons who may be present when an
intervention is carried out are persons who are
necessary for the interventions, unless the
patient consents or requires otherwise
Patient’s admitted to health care institutions
have the right to expect physical facilities which
ensure privacy
 
In some instances the rule of professional
secrecy does not apply and a doctor will not be
liable (not legally responsible) for divulging
information to a relevant third party (Privileged
communications)
 
Such communication should be made with
caution and least embarrassment to the
patient
 
 
Privileged communication
 
(1)
 
In the interest of the patient (conveyed to other
medical colleagues or parents/guardian)
-
 
Referral to health personnel who assists in 
 
the
clinical management
-
 
Parents/guardian, when:
Patient refuses to carry out treatment
Patient has suicidal tendencies
Psychopath with violent anti-social tendencies
Minors/insane persons
 
 
 
(2)
 
In the interest of the patient’s family
-
 
Communicable diseases
 
-
 
AIDS/HIV - to warn the sexual partner
 
(3)
As a Statutory duty laid down by Law
-
 
Notification of infectious diseases
-
 
Registration of births, still births and
 
deaths
-
 
Industrial diseases
-
 
Public health laws (poisons-factories
 
ordinance)
      -
 
Prevention of terrorism act and other
regulations
-
 
Therapeutic abortions
 
  -
 
Drug addicts
 
(4) Notification to police
When a crime is committed against the patient
or by the patient.
-
 
Assaults, RTA
 As a Statutory duty laid down
by Law
-
 
Abortion
 
 
-
 
Poisoning
-
 
Child abuse
 
(5) In the interest of public good
A doctor is not only a health care personnel but
also a citizen of the country with duties to the
society
-
 
Food handlers with chronic infections
 
-
 
Unfit for public service - vehicle 
 
drivers
with epilepsy
 
(6) Courts of Law
 
-
Doctor may ask court to respect his silence
 
-
May ask permission to write the answer without
making it public
 
-
Court can insist that the doctor answers verbally for
all in the Court to hear
 
-
Doctors refusal to answer may result in
imprisonment for contempt of court
 
 
 
-
 
All matters voiced in Court are absolutely privileged
and carry no risk of a subsequent action for
defamation or breach of confidence
 
-
Reports sent to Court on Court orders are also
absolutely privileged
 
-
 
Statements made to state prosecutors and crime
investigators are also absolutely privileged
-
 
A report given to the rival party or a third party
without the consent of the patient amounts to breach
of confidence
 
(7)
Disclosure in self interest
 
-    
When a doctor’s own integrity is threatened
-
In civil or criminal actions against the doctor by the
patient, a doctor can defend himself, by giving evidence
about the patient’s illness. e.g., patient claims that the
doctor did not treat the patient with antibiotics.
(patient had viral infection)
 
-
Information may also be disclosed at the discretion of
the disciplinary proceeding committee in an inquiry
against a doctor
 
 
 
Medical teaching, research and audit
A doctor can report a case without
revealing the patient’s identity
 
Medical records
-
belong to the hospital authority and not to the doctor
unless in the case of private patients.
If records are called for by Court the hospital
authority must submit them confidentially
 
-
 
should not be given to lawyers without prior
consultation with the legal representatives of the
hospital when legal action concerning negligence of
medical or nursing staff in concerned
-
 
records should not be given to employers/insurance
companies without the consent of the patient or if
dead/incapacitated without consent of next of kin
 
Insurance companies
-
 
The medical examination for taking out an
insurance policy is a voluntary act therefore consent
is implied.
 
-
 
Should not give information to an Insurance
Company about a patient’s past medical history, if
the patient has consulted him before.
 
Consent
 
    In medical practice it refers to the
willingness of a person to subject
himself for examination, investigation
and treatment
 
 
Consent is valid when:
free, voluntary, without undue influence
given by a competent person
is informed
  
-
 
information necessary to make
 
therapeutic decision
  
-
 
relevant information about  research
  
-
 
relevant medico-legal information
 
Should be taken from the spouse especially
when it affects the reproductive and sexual
functions permanently
 
May be given by a guardian (proxy consent)
in the case of the mentally retarded, minors
 
Consent
 
   
Implied
 
   Expressed
 
Verbal
Written
Gesture
Written/witnessed
 
Implied consent
 
The behavior of person indicated that the person is
willing for examination and treatment
Consent is implied when
 
-
 
a person voluntarily comes to the OPD/clinic and
 
sits by the doctor
 
-
 
when he gets admitted to a ward
However, this consent is limited to ordinary forms of
examination, investigation, and treatment
 
Expressed consent
 
When consent is not implied, the doctor has to
get consent from a competent patient after
explaining what he is going to do and the
implications of what is to be done. In other
words the patient must express his willingness
for the examination, investigation and
treatment
It must be obtained in the presence of a third
party
 
Gestures :
 
-  
Patient may say yes by nodding the head or
say no by moving the head to and fro sideways
or moving the hand to and fro sideways or by
simply running away
 
-  This type of consent is dangerous as the doctor
really does not know what the patient actually
means by the gesture
 
- A doctor must not be satisfied with consent in
the form of a gesture
 
 
 
 
Oral :
 
- 
Patient will express his willingness by word of
mouth
 
Written :
-
 
The patient will express his willingness in
writing by putting his signature on a printed
form provided by the institution
 
Expressed written consent should be taken….
 
Before invasive examination/treatment
  
- 
Per vaginal examination
  
- Rectal examination
  
- Taking blood for investigations
  
- Intra venous therapy
  
- Chemotherapy, Radiotherapy
  
- Surgery
  
-
 
Any procedure needing anaesthesia
Experimental medicines / clinical trials
 
 
Written and Witnessed:
 
-
 
The patient will express his willingness in
writing and the fact such signature was free
and voluntary and obtained after explaining
the procedure and the consequences and is
witnessed by a third party
 
 
All medico—legal examinations where persons
are produced from custody require expressed
written witnessed consent
 
 
- 
 
examination for drunkenness
-
 
victims of sexual offences
-
 
assailants of sexual offences
-
 
suspects/accused produced by police
 
-
 
examinations for insanity
-
 
any other person produced from 
 
custody
 
 
 
Such consent is also required from next of kin
for pathological autopsies and removal of
organs
 
However if such person refuses to subject
himself for examination, the doctor cannot
proceed to examine him against his expressed
wishes
 
Consent by Others
-
 
In the case of minors and others who are
 
incapable of giving valid consent, the
 
consent of the parent or guardian is required
-
 
When there is no such parent or guardian, a
court order may be obtained
 
     - No examination can be carried out at the
 
request of a police officer or an employer
 
without consent
 
In the case of school children in state schools,
even though the consent of the parents is not
required, the objections of the parent is
upheld on condition that they arrange their
own GP to conduct an examination.
 
 
 
-
 
Consent for procedures involving marital
rights such as sterilizations, termination of
pregnancy, the consent of the spouse is
obtained to preserve family harmony even
though it is not legally required
-
 
If the procedures are carried out to save the
life or preserve health of spouse, there is
absolute no need for consent of other spouse
 
Instances when consent is not necessary
 
Emergency
Mandatory vaccination requirements
Statutes requiring quarantine in cases of
contagious diseases
Examination under court order
 
Conflicts
 
During the delivery of a baby, problems
develop and you are faced with a choice.
The mother or the child?
Whose autonomy prevails?
Non-maleficience (but to whom?)
Beneficence (to whom?)
Justice (to whom?)
 
 
A young teenage mother who was a victim of
rape came to the hospital for an abortion.
 
What will you do?
What moral principles?
 
Ethical Dilemma (1)
 
The abortion was performed but the abortus
was “alive”.
 
What will you do?
What moral principles?
 
The son of a colleague has come forward to
offer part of his liver for a “live donor
transplant”.
 
What would you do?
What moral principles?
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Medical confidentiality is crucial in maintaining trust between doctors and patients. Breaching confidentiality can lead to legal consequences. Various oaths and codes emphasize the importance of keeping patient information confidential, even after their death. Guidelines stress that patient consent is essential for disclosing information, and all patient data must be protected. Understanding the definition, rules, and implications of confidentiality is vital for healthcare professionals.


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  1. Confidentiality Prof. Jasim N. Al-Asadi 2018-2019

  2. Learning objectives 1. To know the definition of confidentiality and its basic rules 2. To Identify which information is confidential 3. To describe when confidential information may be disclosed 4. To describe how best to document disclosures of confidential information 4. To Apply their knowledge to synthesize possible approaches to solve the problems associated with breaking confidentiality

  3. Confidentiality The doctor patient relation ship is an extremely confidential one All information that the doctor has acquired professionally should be kept strictly confidential (Professional secrecy)

  4. Breach of this duty can lead to a civil law suit or criminal defamation if done intentionally Divulging such information to a third party (e.g., insurance company or employer) should be done with consent only

  5. Hippocratic Oath Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret

  6. The declaration of Geneva of 1948 I will respect secrets confided in me, even after the patient has died

  7. The international code of Medical Ethics amended in Venice in 1983 A physician shall respect the rights of patients, colleagues and of other health professionals and shall safeguard patient confidences A physician shall preserve absolute confidentiality on all he knows about his patient even after the patient is dead

  8. WHO guide lines on Medical Confidentiality All information must be kept confidential Information can only be disclosed if the patient gives explicit consent, or if the law specifically provides Consent may be presumed where disclosure is to other health care providers involved in that patient s treatment All identifiable patient data must be protected

  9. Medical interventions may only be carried out when there is a proper respect shown to the privacy of the patient. This means that the only persons who may be present when an intervention is carried out are persons who are necessary for the interventions, unless the patient consents or requires otherwise Patient s admitted to health care institutions have the right to expect physical facilities which ensure privacy

  10. In some instances the rule of professional secrecy does not apply and a doctor will not be liable (not legally responsible) for divulging information to a relevant third party (Privileged communications) Such communication should be made with caution and least embarrassment to the patient

  11. Privileged communication

  12. (1) In the interest of the patient (conveyed to other medical colleagues or parents/guardian) - Referral to health personnel who assists in the clinical management - Parents/guardian, when: Patient refuses to carry out treatment Patient has suicidal tendencies Psychopath with violent anti-social tendencies Minors/insane persons

  13. (2) In the interest of the patients family - Communicable diseases - AIDS/HIV - to warn the sexual partner

  14. (3) As a Statutory duty laid down by Law - Notification of infectious diseases - Registration of births, still births and deaths - Industrial diseases - Public health laws (poisons-factories ordinance) - Prevention of terrorism act and other regulations - Therapeutic abortions - Drug addicts

  15. (4) Notification to police When a crime is committed against the patient or by the patient. - by Law Assaults, RTA As a Statutory duty laid down - Abortion - Poisoning - Child abuse

  16. (5) In the interest of public good A doctor is not only a health care personnel but also a citizen of the country with duties to the society - Food handlers with chronic infections - Unfit for public service - vehicle drivers with epilepsy

  17. (6) Courts of Law - Doctor may ask court to respect his silence - May ask permission to write the answer without making it public - Court can insist that the doctor answers verbally for all in the Court to hear - Doctors refusal to answer may result in imprisonment for contempt of court

  18. - All matters voiced in Court are absolutely privileged and carry no risk of a subsequent action for defamation or breach of confidence - Reports sent to Court on Court orders are also absolutely privileged - Statements made to state prosecutors and crime investigators are also absolutely privileged - A report given to the rival party or a third party without the consent of the patient amounts to breach of confidence

  19. (7) Disclosure in self interest - When a doctor s own integrity is threatened - In civil or criminal actions against the doctor by the patient, a doctor can defend himself, by giving evidence about the patient s illness. e.g., patient claims that the doctor did not treat the patient with antibiotics. (patient had viral infection) - Information may also be disclosed at the discretion of the disciplinary proceeding committee in an inquiry against a doctor

  20. Medical teaching, research and audit A doctor can report a case without revealing the patient s identity

  21. Medical records - belong to the hospital authority and not to the doctor unless in the case of private patients. If records are called for by Court the hospital authority must submit them confidentially - should not be given to lawyers without prior consultation with the legal representatives of the hospital when legal action concerning negligence of medical or nursing staff in concerned - records should not be given to employers/insurance companies without the consent of the patient or if dead/incapacitated without consent of next of kin

  22. Insurance companies - The medical examination for taking out an insurance policy is a voluntary act therefore consent is implied. - Should not give information to an Insurance Company about a patient s past medical history, if the patient has consulted him before.

  23. Consent

  24. In medical practice it refers to the willingness of a person to subject himself for examination, investigation and treatment

  25. Consent is valid when: free, voluntary, without undue influence given by a competent person is informed - information necessary to make therapeutic decision - relevant information about research - relevant medico-legal information

  26. Should be taken from the spouse especially when it affects the reproductive and sexual functions permanently May be given by a guardian (proxy consent) in the case of the mentally retarded, minors

  27. Consent Implied Expressed Verbal Written Gesture Written/witnessed

  28. Implied consent The behavior of person indicated that the person is willing for examination and treatment Consent is implied when - a person voluntarily comes to the OPD/clinic and sits by the doctor - when he gets admitted to a ward However, this consent is limited to ordinary forms of examination, investigation, and treatment

  29. Expressed consent When consent is not implied, the doctor has to get consent from a competent patient after explaining what he is going to do and the implications of what is to be done. In other words the patient must express his willingness for the examination, investigation and treatment It must be obtained in the presence of a third party

  30. Gestures : - Patient may say yes by nodding the head or say no by moving the head to and fro sideways or moving the hand to and fro sideways or by simply running away - This type of consent is dangerous as the doctor really does not know what the patient actually means by the gesture - A doctor must not be satisfied with consent in the form of a gesture

  31. Oral : - Patient will express his willingness by word of mouth Written : - The patient will express his willingness in writing by putting his signature on a printed form provided by the institution

  32. Expressed written consent should be taken. Before invasive examination/treatment - Per vaginal examination - Rectal examination - Taking blood for investigations - Intra venous therapy - Chemotherapy, Radiotherapy - Surgery - Any procedure needing anaesthesia Experimental medicines / clinical trials

  33. Written and Witnessed: -The patient will express his willingness in writing and the fact such signature was free and voluntary and obtained after explaining the procedure and the consequences and is witnessed by a third party

  34. All medicolegal examinations where persons are produced from custody require expressed written witnessed consent - - - - - - examination for drunkenness victims of sexual offences assailants of sexual offences suspects/accused produced by police examinations for insanity any other person produced from custody

  35. Such consent is also required from next of kin for pathological autopsies and removal of organs However if such person refuses to subject himself for examination, the doctor cannot proceed to examine him against his expressed wishes

  36. Consent by Others -In the case of minors and others who are incapable of giving valid consent, the consent of the parent or guardian is required -When there is no such parent or guardian, a court order may be obtained - No examination can be carried out at the request of a police officer or an employer without consent

  37. In the case of school children in state schools, even though the consent of the parents is not required, the objections of the parent is upheld on condition that they arrange their own GP to conduct an examination.

  38. -Consent for procedures involving marital rights such as sterilizations, termination of pregnancy, the consent of the spouse is obtained to preserve family harmony even though it is not legally required -If the procedures are carried out to save the life or preserve health of spouse, there is absolute no need for consent of other spouse

  39. Instances when consent is not necessary Emergency Mandatory vaccination requirements Statutes requiring quarantine in cases of contagious diseases Examination under court order

  40. Conflicts During the delivery of a baby, problems develop and you are faced with a choice. The mother or the child? Whose autonomy prevails? Non-maleficience (but to whom?) Beneficence (to whom?) Justice (to whom?)

  41. Ethical Dilemma (1) A young teenage mother who was a victim of rape came to the hospital for an abortion. What will you do? What moral principles?

  42. The abortion was performed but the abortus was alive . What will you do? What moral principles?

  43. The son of a colleague has come forward to offer part of his liver for a live donor transplant . What would you do? What moral principles?

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