Understanding Medical Confidentiality and Ethics
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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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
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
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
(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 patients 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. - by Law Assaults, RTA As a Statutory duty laid down - 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.
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 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
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?)
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?
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?
