Doctor-Patient Confidentiality - Case Study Example

Running head: Reflective Paper Reflective Paper: Doctor-Patient Confidentiality School Reflective Paper Introduction Doctor and patient confidentiality is one of the most elemental requisites of a trusting and effective doctor-patient relationship. It is also an element of the health care practice in general, from the doctors, to the nurses, and to the medical orderlies. The details of a patient’s care and a patient’s condition are to be kept confidential between the patient and the members of his health care team. This confidentiality agreement cannot be breached without the patient’s consent because it is the very foundation of the trusting relationship between the patient and his health care givers. A patient can be forthright with his doctor when he knows that he can trust his doctor with the intimate details of his life. These intimate details often make a difference in the accuracy of the care administered to the patient. There may be instances however, when a doctor or a medical professional may be tempted to breach this agreement. This may be seen in the case of a doctor testing a patient’s blood and later uncovering that the patient has AIDS. A patient may request that his wife not be informed of his condition. In this case, an ethical dilemma is created and we are prompted to ask: Should the doctor honor the patient’s request, or should he tell the wife? This paper shall now attempt to answer this query, using a theoretical and careful assessment of the subject matter. It shall also attempt to settle this issue based on a thorough and logical consideration of its critical discussion points. Discussion AIDS is one of the most volatile diseases in the world. There is currently no cure for it and the management of its symptoms has not reached effective standards for the people to declare safety against contamination from this disease. AIDS is acquired through sexual intercourse with an infected person or through the sharing of needles with infected persons (AIDS.org, 2010). Mothers who breastfeed their babies can also transmit the disease to their babies. In this case, the husband has a high possibility of later infecting (if he has not done so already) his wife with AIDS. This is the crucial dilemma for the doctor. As the doctor honors his confidentiality agreement with the patient, he is placing the wife in danger of being infected by the husband’s virus. Doctor-patient confidentiality is a patient privilege protected by the laws. It is incumbent upon the doctor to keep patient information private, lest suffer the legal consequences of his actions. The settlement of any ethical dilemma in health care involves four basic ethical principles, namely, autonomy, non-maleficence, justice, and beneficence. First and foremost, from the principle of autonomy, the rule of confidentiality flows. The principle of autonomy specifies the right of a patient to make his own decisions about his health and his care (Fulford, Dickenson, & Murray, 2002). This principle implies that a patient should be informed of all the risks and the pertinent details about his disease and his health in order for him to be able to make an informed decision about his care. In this case, the AIDS patient has the right to be informed of the risks in relation to his health and his disease and to make the decisions regarding his care. He also has the right to dictate the type of care he would need. Strictly based on this principle, he also has the right to inform the physician of his preference not to have his disease be revealed to his wife. According to this principle of autonomy, the patient has the right to demand that his wife not be informed of his disease therefore it would be unethical for the physician to go against the patient’s preference. The above principle is however, not absolute. Beauchamp and Childress (2001) discuss that the principle of autonomy is not independent of three other ethical principles, that of nonmaleficence, beneficence, and justice. In some circumstances, Overberg (2006), claims that the three different principles are even more important than the principle of autonomy. Two important considerations still dominate every discussion on ethics – one is on the deep respect for the individual and second, the deep respect which is owed to the community. Satisfying one over the other can create a tough dilemma for any health care professional. “Human dignity demands that the first move must always be towards confidentiality and truth telling. But there may be times (as we have seen) that the common good outweighs individual rights” (Overberg, 2006, p. 55). In this case, the common good surely outweighs the right of the patient to confidentiality. The principle of beneficence alone can be used to counteract the autonomy defense of the patient. Beneficence requires that “in the process of making positive contributions, harm to individuals must be minimized” (Grace & Grace, 2006, p. 178). In the case being discussed, harm must be avoided and minimized. The patient’s AIDS is bad enough as it is that its effects to other people, at the very least, should be avoided or minimized. Informing the patient’s wife of the patient’s disease will help minimize the effects and the spread of the disease. The principle of nonmaleficence, according to Beauchamp & Childress (2001, p. 114), revolves around four main statements: “one ought not to inflict evil or harm; one ought to prevent evil or harm; one ought to remove evil or harm; and one ought to do or promote good”. The very act of not informing the wife of the imminent risk to her health and her life is an act which already inflicts evil; therefore, such evil should be prevented or removed. Moreover, for the benefit of the wife, the husband and the physician ought to do or promote good by informing her of the husband’s disease. Finally, the principle of justice is a broad and clear enough principle to justify the actions of the physician. Justice is a principle which “involves treating every person with equal respect because that is what each is due” (Pojman & Fieser, 2006, p. 143). In applying this principle to this case, we consider what is due the husband – confidentiality – and what is due the wife – being warned of the imminent threat to her life. Although the husband is justly entitled to his confidentiality, his refusal is costly to the life of his wife, who is unaware of the threat to her life and her health. Justice dictates that she be given her due, and her due is the disclosure of the risks she has incurred as a sexual partner. Through the above ethical principles, specifically, through the principles of beneficence, nonmaleficence, and justice, it is ethically sound for the physician to reveal to the wife about her husband’s disease. Due to the societal stigma often attached to AIDS patients, many countries and U.S. states have adopted laws in order to increase protection for the records of HIV-AIDS patients. According to Wolf (2001), some states have mandated that HIV-related information should not be disclosed “based on a general release of medical information-specific authorization for release of HIV-related information”. Unless specifically allowed by the patient, pertinent details of an HIV patient’s chart and medical information must remain protected. It is important to note however, that the laws also indicate an exception to this rule. Drawing from the principles set forth by the Tarasoff v. Regents of the University of California case, “the protective privilege ends where the public peril begins” (as cited by Fruman, 1991). There is a public peril, as far as the wife is concerned, of being exposed and afflicted by a potential deadly disease. In this regard, the confidentiality agreement can be legally breached. Lenihan (1999) discusses that in 1991, patient Gad Joseph informed his mental health counselor that he was going to kill his former girlfriend Teresa Hausler. After a counseling session, his counselor managed to convince him not to hurt Teresa. Gad Joseph ignored the counselor’s advice and in a raging fit, shot Teresa to death (Lenihan, 1999). This case set the trend for decisions which was also followed and adopted in the Tarasoff v. University of California for cases involving the doctor’s duty to warn a third party of his patient’s intentions and of the harm the latter presents to other people. The Tarasoff case “concluded that the relationship between a mental health care professional and his patient constituted a special relationship imposing upon that professional a duty to protect a third party against harm” (Lenihan, 1999). There is an inherent danger or threat to a person’s life attached to the situation and a person has the right to be informed of the threat and make his own decision on the need to protect and how to protect himself from the situation. The important consideration in this case is to let the third party be informed and to give him the chance to address the situation. In this case, the wife has the right to be informed of her husband’s AIDS because her husband’s disease can potentially endanger her health and her life. She should be given the chance to make the decisions about their sexual relations and with the full knowledge of the circumstances of her husband’s health. The details of the Tarasoff case fit the current circumstances of this case. There is an imminent danger to the life and health of a patient, which the doctor has become privy to in the course of treating the patient. Knowing that the disease can be transmitted sexually, the doctor is also aware that the patient’s wife is exposed to a health risk in the form of her husband’s disease. Therefore, the duty to warn the third party of the imminent danger to her life and health is a protected by legal jurisprudence. Various cases in the United States demonstrate why a breach of this confidentiality may be considered legal. In a 1990 Pennsylvania case, a physician did not provide accurate information to his patient, who was a blood technician and who contracted hepatitis and later infected her boyfriend with the disease. Public policy holds, in this case, protection of the general public (or the foreseeable victims) from communicable diseases (Lenihan, 1999). The foreseeable victim, in this case, is the wife. Had the patient revealed any other sexual partners, the duty to warn would extend to them. They too are foreseeable victims of the disease. The legal mandate only relates to these foreseeable victims, not to any other individual. For other individuals of unrevealed sexual partners, the patient confidentiality rights are firmly in place. The doctor cannot actively seek out the patient’s other sexual partners (unless their identity is revealed by the patient) and warn them of the danger to their lives (Lenihan, 1999) Based on the Confidentiality of HIV-Related Information Act, a physician may reveal HIV-related data to a known sexual or blood contact of the patient (Lenihan, 1999). The law also specifies that the physician may reveal information if he sees it to be medically appropriate and there is a risk of future infection to the contact (Lenihan, 1999). The physician is also required to inform the patient that he will reveal to the contact about the patient’s AIDS. The act of locating and tracing unknown third parties who may have been infected by the patient’s AIDS is however beyond the doctor’s authority (Lenihan, 1999). The main point of the law is on notifying known contacts of the patient. These provisions of the law reveal important details which the physician must follow. In this case, he has a duty to reveal to the wife – the known sexual contact – about the husband’s disease. Before he reveals such details to the wife, he has to inform the husband of his intentions, and in the process counsel his client about his own decision regarding his disease. While counseling the patient, the physician may be able to convince the patient himself to reveal to his wife his health problem. If the husband insists on not revealing his disease, the physician must then inform the wife about the husband’s condition. Understandably, the rule of confidentiality is in place in order to protect the client from possible discrimination and from being exposed to the stigma often attached to AIDS sufferers. In the workplace and even in the social sets, the discrimination and the stigma placed on AIDS sufferers is great. Hence, many AIDS sufferers prefer to shun the limelight and not to let other people know about their disease. They seek to protect their identity in order for them to live a semblance of a normal life in the best way they can. It is also important for them to be able to trust their medical provider to keep their medical information as private as possible. This privacy agreement between the patient and the physician gives the patient a chance to open up to his physician without any fear of having his condition broadcasted to other people. When a physician reveals confidential data about the patient to other people, the trust between patient and physician is broken. For physicians who have a reputation of revealing HIV-related data of their patients to other people, their patients may sometimes end up shifting physicians or withholding information from their physician entirely (AIDSLaw, n.d). When this trust is lost, a physician would lose the opportunity to counsel the patient about his disease. In the process, the physician may lose the power to prevent others from being infected by the patient’s disease (AIDSLaw, n.d). In the process of disclosure, the physician “should also be aware that making an unnecessary disclosure or making a disclosure in a way that needlessly frightens or alarms the contact could make [the physician] liable to the contact for the emotional harm…caused that person” (AIDSLaw, n.d, p. 9). The physician should therefore assess and determine that there is indeed a realistic risk of infection. In this case, there is a realistic risk of infection. It is reasonable to expect that the husband would have sexual relations with his wife even after he is diagnosed with AIDS. The act of informing the contact should also be a health education process – where the physician has to inform the contact of the implications of the disease, its symptoms, risks, available treatment options, and management interventions (AIDSLaw, n.d). This information helps to put things into perspective for the contact and would encourage her to undergo tests and precautionary measures to prevent the spread of the disease. The bottom line, after all, in the physician’s decision to inform the contact – in this case, the wife – is to limit the spread of the disease. Even as the duty of confidentiality and the duty to warn is crucial to the evaluation of this case, truthful communication plays an even more crucial role in settling this ethical dilemma. Honesty between the patient and the physician is an important requirement in the doctor-patient relationship because it helps ensure that an accurate diagnosis and consequently, an accurate treatment for the patient can be implemented. For the physician, his honesty will also help ensure that the bounds and the coverage of his responsibilities are defined for the patient; that he does not take credit for something beyond what he can actually deliver. Ostrow (1990, p. 302) discusses that “the ability of the patient to make decisions regarding the type and extent to care desired, the types of medications and procedures he/she wishes, and the ultimate disposition of belongings, depends in large measure on the patient’s being fully and honestly informed of the implications of his/her medical status”. The truthful communication between patient and physician must indicate that although the physician has a duty of confidentiality – that such duty is not absolute. Even as the patient relies on such duty while he discloses all his health issues to the doctor, he is to be informed by the physician that such duty has exceptions. In this case, the physician must explain to the patient that the duty of confidentiality is not absolute – that in favor of public interest and of the interest of specifically identified persons exposed to health risks, such duty must be breached. With this awareness, the patient will be better informed that the breach is not a willful and destructive act, but it is an act carried out after deliberate analysis, careful deliberation, and after an honest and earnest attempt at convincing him to do the right thing for his wife. Conclusion After considering the above discussion, it is ethically and legally sound for the physician to inform the wife of the fact that her husband has AIDS. Based on the ethical principle of autonomy, the patient has the right to confidentiality. He has the right to demand that the physician not reveal his disease to his wife. However, this right is not absolute. Based on the principles of beneficence, nonmaleficence, and justice, the physician is ethically bound to reveal the husband’s condition to the wife. Where the common good is concerned, the individual’s rights should be sacrificed. Legal mandates also speak of the physician’s duty to warn a third person of an imminent danger to his life. In the Tarasoff case, the courts decided that a physician privy to an imminent threat to another person’s life as gleaned through a patient-doctor relationship, that a third person must be informed of the threat to his life. In the process of assessing the patient’s circumstances, the physician must however consider the patient’s case – if it is an immediate and specifically identified threat. In this case, the threat is identified and is specific enough. The physician must also try his best to counsel the patient – for the latter to inform his wife of his disease. When all else is exhausted and the threat or risk on the wife is still there, then the physician can legally breach the confidentiality agreement with the patient. He must also inform the patient of his intentions to notify his wife. Based on these points of discussion, the physician can legally and ethically inform the wife of her husband’s condition. Works Cited AIDSLaw. (n.d) Confidentiality Vs the Duty to Warn. AIDSLaw, p. 9. Retrieved June 12, 2010 from http://www.aidslaw.org/confidentiality.pdf. AIDS.org (2010) What is AIDS? AIDS.org. Retrieved June 12, 2010 from http://www.aids.org/factsheets/101-what-is-aids.html. Beauchamp, T. & Childress, J. (2001) Principles of biomedical ethics, p. 114. New York: Oxford University Press. Fruman, L. (1991) AIDS and the physicians duty to warn. Medicine and Law, 10(5), 416-443. Fulford, K., Dickenson, D., & Murray, T. (2002) Healthcare ethics and human values: an introductory text with readings and case studies. Massachusetts: Blackwell Publishing. Grace, P. & Grace, P. (2009) Nursing ethics and professional responsibility in advanced Practice, p. 178. Massachusetts: Jones & Bartlett. Lenihan, L. (1999) Physician duty to warn third parties. Physician’s News. Retrieved June 13, 2010 from http://www.physiciansnews.com/law/899lenihandv.html. Ostrow, D. (1990) Behavioral aspects of AIDS, p. 302 New York: Plenum Publishing. Overberg, K. (2006) Ethics and AIDS: compassion and justice in a global crisis, p. 55. Maryland: Rowman & Littlefield. Pojman, L. & Fieser, J. (2006) Ethics: Discovering Right and Wrong, p. 143. California: Cengage Learning. Wolf, L. (2001) Ethical Dimensions of HIV/AIDS. HIV InSite. Retrieved July 12, 2010 from http://hivinsite.ucsf.edu/InSite?page=kb-08-01-05. Read More