Week 5

Question 1

What is moral obligation in terms of confidentiality?

Answer 1

Trust in a doctor-patient relationship depends on confidentiality.

Question 2

What is legal obligation in terms of confidentiality?

Answer 2

Not to divulge information obtained in the course of medical information.

Question 3

What type of information is confidential?

Answer 3

• All identifiable patient information, whether written,
  computerised, visual or audio recorded or simply held in the
  memory of health professionals, is subject to the duty of
  confidentiality.
• This covers:
  1. Any clinical information about an individual’s diagnosis or
  treatment
  2. A picture, photograph, video, audiotape or other images of the
  patient
  3. Who the patient’s doctor is and what clinics patients attend and
  when
  4. Anything else that may be used to identify patients directly or
  indirectly.

Question 4

Why should patient information be held confidential in terms of ethical justification?

Answer 4

1. Patient autonomy
   * Personal information belongs to the patient
   * Respect for autonomy by not disclosing information without consent
2. Virtue ethics
   * A virtuous doctor should be sensitive/responsible/trustworthy and
   respect patients’ confidences
3. Consequentialism
   * If doctors keep confidentiality, patients trust doctors and are more
   possible to disclose relevant information
4. Rights and privacy
   * Patient right to decide who should have access to personal information &
   authorise them
5. Differentiate between personal information a patient wants to keep secret
   and information they are willing to have disclosed to others
6. Implied promise
   * Confidentiality assumed in doctor-patient relationship
   * to break confidentiality is to break a promise made to the patient
7. Trust
   * precondition for sharing personal information
   * ethical and legal standards of confidentiality as integral part of Doctor-patient relationship

Question 5

What conditions establish a duty of confidentiality?

Answer 5

1. Information must have an inherent quality of confidentiality as
   obtained in medical practice
2. Information given in clinical context implies an obligation of
   confidence
3. Unauthorised disclosure would bear consequences/cause some harm
   to the provider

Question 6

What is the WMA’s international code of medical ethics?

Answer 6

“It is ethical to disclose confidential information when the patient
consents to it or when there is a real and imminent threat of harm
to the patient or to others and this threat can be only removed by a
breach of confidentiality.”

Question 7

What are the secondary uses of patient information?

Answer 7

• Use of data in medical research
  -prior consent, anonymized data
• Clinical audit
  -often undertaken under the presumption of implied consent
• Conference presentations, educational publications;
  -prior consent

Question 8

When is confidentiality normally breached?

Answer 8

Routine situations:
* Access of nurses, medical students etc to patient record
* Use of interpreters to facilitate communication when doctor-patient do
not speak the same language
* Information shared with proxy decision-makers
* Information shared with family of a patient in critical care or a deceased
patient

Question 9

When does accidental/ unintentional breach take place?

Answer 9

• Lifts and Canteens: Discussing information in crowded places.
• A&E departments and Wards: many people in close proximity to
  health-care professionals discussing information about a patient.
• Patient Notes: left in an area with open access, e.g. on the
  receptionist’s desk where other patients/visitors can see them.
• Computers, faxes, and Printers:
• personal information about patients on faxes or print-outs which
  have not been filed away promptly
• computer screen with previous patient’s details visible to the next
  patient

Question 10

How can confidentiality on the internet be breached?

Answer 10

• potential risks of inadvertent breaches when using social
  networking sites to communicate either personally or
  professionally
  -duty to protect patient confidentiality extend to the Internet
  -users must be particularly mindful to not disclose any identifying
  information, ie date/location of event, patient-specific details

Question 11

How can confidentiality be breached on social media?

Answer 11

• Social media can blur the boundary between private and
  public domains
• individual pieces of information taken in sum may be identifiable
  patient confidentiality violations
• Maybe be accused of misconduct or ‘minor breach of
  confidentiality’

Question 12

When may confidentiality be breached?

Answer 12

1. When the patient gives consent
   ▪Sharing clinically relevant information with other staff to assist in the
   management of a patient.
   ▪Sharing information with family members
2. Instances where doctors are required to breach confidentiality
3. Other circumstances where there would be considerable defense

Question 13

What are the justifications for breaking confidentiality?

Answer 13

1. With patient’s Consent
2. In the patient’s best interests
   -Incompetent patients
   -Children
3. In the public interest
   -Public safety
   -Public health
   When the public interest in breaking confidentiality
   outweighs the public interest in maintaining
   confidentiality
4. Disclosure required by law/courts/approved through
   statutory process

Question 14

What are some particular example problems of confidentiality?

Answer 14

1. The impaired driver
   * Driver Vehicle and Driving Agency (DVLA) – establishing fitness to
   drive
   * Doctors have professional obligation to ensure that the DVLA is
   aware of anyone medically unfit and unsafe to drive
2. Abused patient
   * Limits to intervention for adult capacitous patients
   * In the case of a child, there is special guidance to report under
   Child Protection and Safeguarding
3. Patient with gunshot or knife wounds
   * Doctors should inform the police
   * Consider whether patient poses risk of serious harm to others
4. The drug dependent patient
   * duty of confidentiality to drug-abusing patient same as with any
   other patient
   * But prescribing controlled drugs to be recorded in the drug
   misuse database
5. Request to report to the police
   * In general, no obligation to report to the police
   * the police do not have automatic powers to demand disclosure
   * But exceptions (i.e. traffic accidents, serious crimes, terrorist acts)
   * Personal identifiers vs clinical record
   * Good practice to ask for written request
6. Sexually active minor
   * Sexually active young people present an especially difficult area;
   explore abuse vs consented
   * Fear about confidentiality deters some teenagers from seeking
   early sexual health advice
   * Young people need to trust the confidentiality of general practice
   to seek advice on other personal issues too, such as drugs,
   bullying and depression
   7.Communicable disease
   * A doctor must notify the relevant local authority officer if
   they suspect a patient of having a notifiable disease (i.e. TB;
   COVID-19)
   * AIDS and HIV are not notifiable diseases.
   * Disclosure of information to a partner in the public interest
   * There must be a real and serious risk of physical harm to an
   identifiable individual
   * Disclosure must be made only to those who are in vital need of the
   information

Question 15

When can you breach confidentiality against a child’s wishes?

Answer 15

• (a) overriding public interest
• (b) best interest of incompetent child
• (c) disclosure required by law

Question 16

What must you do when disclosing information about a patient?

Answer 16

1. Use anonymised information if it is practicable to do so and if it will
   serve the purpose
2. Satisfy the patient:
   * has ready access to information explaining how their information will be
   used and that they have the right to object
   * has not objected
3. Get the patient’s explicit consent if identifiable information is to be
   disclosed for purposes other than their direct care or local clinical audit,
   unless the disclosure is required by law or in the public interest
4. Keep disclosures to the minimum necessary for the purpose
5. Follow all relevant legal requirements, including data protection law.