Confidentiality, Privacy,

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• Confidentiality, Privacy,
• Duty to Warn
• Philip Boyle, Ph.D.
• Vice President, Mission Ethics
• www.CHE.ORG/ETHICS
• \Topics
• \Confidentiality

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Goals for todays conversation

• Understand the limits and obligations with
  confidentiality and the duty to warn
• How can reflecting on todays cases be used for
  total quality improvement?

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Problem

• Confidentiality--sleeper issue compared to life
  and death issues
• General agreement confidences are to be kept
• Moral problem no clear lines draws a different
  line in the sand.
• Practical problem
• How to come to a consensus?
• What protections and education need to be put
  into place?
• Unique problems in long term, home health,
  behavioral care
• Intimate knowledge about a persons life often
  can help in promoting care
• Health care professionals need to be even more
  vigilant about what information is necessary or
  unnecessary

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• Why do we hold confidences?
• When do we break confidences?
• What are the considerations under which we can
  break them?
• Framing question Is this an issue of blocks to
  knowledge or what knowledge is need to be known?

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Examples

• Transmissible disease
• Potential harm to others
• Common medical patient rounds
• Genetics and information about future generations
• Medical chips in the arm or under the
  fingersuper medic alert bracelet
• Social factors that may or may not be relevant to
  treatment of patient
• Knowing lots about people in long-term care home
  health
• Sexual behavior in long-term care

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Examples

• Behavioral health, especially rural setting
• HIPPA
• Things that are said in casual conversation
  dont count.
• Translation services and cultural sensitivity
• Requests from adolescents e.g., birth control
• Organizational ethics issues confidentiality
  with respect to working history e.g., a nurse who
  has diverted drugs, Michael Swango/Charles Cullen
• Discovery of medical error or knowledge of a near
  miss

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Definition

• Confidentiality Obligation not to pass along to
  anyone information about another without their
  permission not gossiping, not passing on rumors
• Privacy right to be left alone and free from
  unwarranted publicity

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Why is confidentiality so hard to address?

• Not a life and death issue
• Breaches are not done with malice
• Perpetrator does not see the harm
• Harm is more often psychological and no physical
  harm
• Persons whose confidence is breached may not see
  problem, or may not be a problem if seen
• Little personal cost to perpetrator
• No institutional sanctions

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Ethical underpinnings of confidentiality

• Hippocratic oath Whatever I shall hear in the
  course of my profession, as well as outside my
  profession in the intercourse of men, if it
  should not be published abroad, I will never
  divulge it, holding such a thing a holy secret.

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Ethical underpinnings of confidentiality

• Patient Bill of Rightseven more restrictive The
  patient has the right to every consideration of
  privacy concerning her medical careThose not
  directly involved with her care must have the
  permission of the patient to be present. That
  patient has the right to consider all records and
  communications pertaining to her care should be
  treated as confidential.

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Ethical underpinnings of confidentiality

• Presumption in favor of confidentiality

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Foundational values

• Therapeutic trust
• Fairness do unto others
• Dignity of the persons
• Burdens-benefit ratio burdens include labeling,
  stigmatizing and perhaps given different care,
  lack of preparedness if relative dont know

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Case

• A 60-year-old man has a heart attack and is
  admitted to the medical floor with a very poor
  prognosis. He asks that you not share any of his
  medical information with his wife as he does not
  think she will be able to take it. His wife
  catches you in the hall and asks about her
  husband's prognosis.
• Would you tell his wife?

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Phase II Decision Making

• 1. Pray, reflect, identify question, and clarify
  authority of decision-making group.
• 2. Determine primary and secondary communities of
  concern and their interests.
• 3. Get facts
• 4. Identify key moral commitments and values, as
  well as conflicts among them.
• 5. Establish priorities among commitments and
  values.
• 6. Develop options that support the priorities.
• 7. In silence reflect and then listen to
  viewpoints.
• 8. Gain consensus on decision.

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Case

• Mrs. P who is incapacitated to make decisions is
  admitted to a nursing home because her son has
  AIDS and is unable to care for her at home. The
  social worker knows the son has a criminal
  record. The son is not the health care agent but
  want to direct care. Should the social worker
  tells the team about the sons past?

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Case

• Marge, a nurse on a behavioral health unit
  recognizes her neighbor George who is admitted
  and proceeds to give him a warm welcome to allay
  his fears. At a weekly case review Marge provides
  information that George is known to be violent,
  especially when because of substance abuse. As
  supervisor, what would you say to Marge?

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CASE

• Your 36-year-old patient has just tested positive
  for HIV. He asks that you not inform his wife of
  the results and claims he is not ready to tell
  her yet.
• What would you say to your patient?
• Why?

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Case

• A 75-year-old woman shows signs of abuse that
  appears to be inflicted by her husband. As he is
  her primary caregiver, she feels dependent on him
  and pleads with you not to say anything to him
  about it.
• How would you handle this situation?
• How is this case different from Case 1?

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Case

• An adolescent seeks treatment from a physician
  for
• Birth control
• Pregnancy test
• Sexually transmitted disease
• Substance abuse
• Her father asks the MD for a conference about the
  adolescent. Which items should the MD disclose?
  Why?

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Case

• A patient confides in a respiratory therapist
  that he is thinking of taking his own life once
  he is discharged from the hospital. Before he
  divulges this information he extracts a promise
  that he will only disclose information under the
  strictest confidence, and the therapist agrees.
  The patient is severely depressed.
• Is the therapist justified in providing this
  information to the physician? Why?

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Case

• A physician, in the course of caring for a
  patient, who is a bus driver, notes that the
  person is at risk for having a heart attack and
  recommends that she cease driving, as she may
  place the children at risk. The driver asks the
  physician not to notify the school district, as
  it would put her at risk of losing her job. The
  physician notifies the district.

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Ethical limitations of confidentiality

• Criteria for a duty to warn
• Innocent third party is a risk
• Immediate
• Severe harm
• Likely to happen
• Intervention can avoid it
• Last resort
• Children and adolescents
• Persons with mental illness

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Phase III Follow Through

• Assign accountabilities to specific persons for
  each component to be realized.
• Build a plan for monitoring and reporting with
  measurable outcomes.
• Build a communication plan for community of
  concern with key messages and methods.
• Build a plan that connects to the larger meaning
  and purpose.

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Practical considerations

• What everyone agrees uponusing information for
  care and not personal gain or mere gossip
• Review and understand the limits of duty to warn
  in your state
• Review and understand HIPPA concerns at your
  institution
• Do not assume that family members or friends have
  permission
• Dont provide information over the phone to those
  whose identity has not be verified

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Practical considerations

• Dont use information that you have from outside
  the health care setting
• Need to know basis
• Moral leadership what information is true or not,
  need to be known or not?
• Signage
• Identifying paraprofessional who may not have a
  clear understanding about the limits of
  confidentiality
• Promoting the practice to converse with immediate
  supervisors