What is confidentiality?
Confidentiality is one of the core duties of a doctor towards their patients as set out by the GMC. It is the duty to keep information about a patient private/ within the healthcare team.
What counts as confidential information?
All identifiable patient information, whether written, computerised, visually or audio recorded, or simply held in the memory of health professionals, is subject to the duty of confidentiality.
Confidentiality is an important legal and ethical duty but it is not absolute.
GMC
Why is it important?
Although confidentiality is not absolute and can be broken (as we will explore below) it nonetheless forms the foundation in the doctor-patient relationship.
Confidentiality is key to building the trust in the doctor-patient relationship, if it were not held to such high regard, patients may be reluctant to seek medical help, may under-report symptoms and may not reveal sensitive information, all of which would impact the quality of care that they receive.
In what circumstances can confidentiality be broken?
It is the requirement that doctors and other healthcare professionals keep their patient’s information private within the healthcare team, apart from in the following circumstances.
- When the patient has consented to share the information (and they have the capacity to consent)
- When the patient lacks capacity and sharing is in the overall benefit of the patient
- When disclosure is required by statute e.g in relation in certain communicable diseases.
- When it is required by a court order
- When it is justified in the public interest i.e when not sharing puts others in danger
Examples include:
- Under the Terrorism Act 2000
- Suspected child abuse
- If a patient has one of the listed communicable diseases such as TB, typhoid, measles, cholera, but not AIDS, this is informed to appropriate government authorities
- May be required to inform DVLA if the patient continues to drive despite warning e.g if epileptic
Confidentiality in a modern world – Genetic testing
The risk of confidentiality breaches has increased significantly with the electronic storage of data and modern genetics is testing our traditional view on confidentiality.
Who has the right to genetic information? In a paternity test where the ‘father’ is not the biological father, most geneticists would respect the mother’s right to confidentiality and not disclose this- The influential Committee on Assessing Genetic Risks at the Institute of Medicine in the US recommends that ‘Genetic testing should not be used in ways that disrupt families’ – there are some great examples of this in Tony Hope’s medical ethics book.
But this becomes tricky, especially in cases where genetics tests are available for inheritable diseases such as Huntington’s or Duchenne Muscular Dystrophy.
Below is an article of a woman who was not informed that her father had a Huntingdon’s disease. She told the High Court that she would have had an abortion if she’d known at the time of her pregnancy.
https://www.bbc.co.uk/news/health-50425039
This is an ethically difficult scenario and there are two frames or approach here (as explored in more depth in Tony Hope’s Medical Ethics: A very short introduction)
- The personal account model: The conventional view on confidentiality i.e the father’s genetic state ‘belongs’ to him alone, therefore cannot be shared with family members without valid consent
- The joint account model: Or genetic information could be seen in a completely different way to all other medical information and should be made available to all genetically related family members unless there are good reasons to withhold the information. In this case, this information affects the choices the daughter makes.
As genetic testing and science advance, the rules and guidance surrounding confidentiality have to continually evolve as well.
In this part of the post, we will tackle the questions at the end of last week’s post. Let’s bring together all the principles we have learnt so far.
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Doctors are in the cafeteria discussing a night out with the public around, their feet are on the chairs and they are dropping crisps on the floor. Discuss the issues here and an appropriate course of action.
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- The overarching concern here is the impact these doctors are having on the public’s perception of the medical profession
- The discussion of a night out and a disregard for the environment they are in conveys a lack of respect and may cause the public to lose confidence in them. This loss of trust due to the lack of professionalism will impact the doctor-patient relationship and may go on to impact on the quality of care the patient receives.
- Similarly, public discussion in this way can easily slip to reveal confidential information about patients, breaching the duty of confidentiality- this is something I would be wary of although this is not what is happening at present.
- The course of action here would largely depend on my position, for example, I could politely mention that this sort of behaviour is not appropriate in this setting and I would hope that the doctors would be receptive and move their conversation somewhere more private. On the other hand, I could inform a more senior member of the team if I didn’t feel comfortable approaching the situation myself- although this approach may not have an immediate effect.
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You are a GP and see a 16 -year-old girl who has revealed that she is being abused by her parents, she has fresh burns and begs you not to tell anyone. Discuss your approach to this issue.
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We will soon cover consent and capacity with children but here’s an answer to familiarise yourself.
- Here, the overarching issue is balancing our duty of confidentiality and safeguarding (remember confidentiality is owed to all patients including those under 16).
- The first port of call would be to address the patient’s wounds, as she has fresh burns she may be in pain and thus this would be the most immediate action taken- may refer to paediatric specialists to treat the burns. (pick up on these details when reading a role-play/ ethical prompt)
- I would try to gather more information about her situation, why does she not want to disclose this information, what are her concerns if she does so?
- I would reassure her that we can help and prevent further abuse from taking place.
- Importantly, I would discuss this issue in partnership with the patient and I would avoid being condescending but rather gain her trust and together make a plan going forward.
- As this is a serious safeguarding concern it would be inappropriate for me to discharge the patient right away, i.e they may go home and be subject to further abuse, thus I must act promptly and efficiently.
- Suspecting child abuse does not automatically mean breaching confidentiality, and I would first try and gain their consent (after having a discussion).
- Where consent is denied, the young person should be kept informed about the process, but I would nonetheless act in their best interests and contact local child protection services.
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An elderly lady is refusing medication for a heart condition, you are her doctor, discuss this situation.
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- First of all, I would explore why she has stopped, for example, it may simply be due to the side effects in which case adjustments can be made to minimise this/ look for alternatives
- I would also check whether this patient has an understanding of what the medication is for (checking the patients understanding is a great technique in role plays), for example, do they understand the impact of not taking the drug
- In this way, I would take the necessary steps to ensure that this patient is making an informed decision.
- I would clearly explain the importance of controlling her heart problem, for example, she may not think she has any symptoms e.g high blood pressure, but the effects of these problems manifest in more serious consequences e.g heart attack/ stroke/ eye problems etc. To improve my communication of these ideas I would use simple language and use diagrams.
- If when given all this information, the patient still refuses and you deem them to be a competent adult, as a doctor you must respect their right to autonomy
- I would also give the patient time to process this information for example, they may want to go away and think about it- this is fine.
- The situation becomes more nuanced if you have concerns over her capacity e.g she may have dementia (although this in itself does not mean she lacks capacity)/ or she may be under the Mental Health Act, in which case a decision would be made in her best interests – this scenario will be covered in-depth in the next blog post
- Other things to look out for in a role play is whether they are accompanied by someone e.g if she is accompanied by her husband and she appears very anxious you may consider whether there is a social factor here and kindly request to see her alone.
- In conclusion, this scenario focuses on addressing the patient’s concerns and reasons for stopping their medication and taking relevant steps to ensure that this is an informed decision.
Here’s another great resource BMA medical student toolkit: https://www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students
I hope you found this blog post helpful, let me know in the comments below/ like the post. I’d love to hear your thoughts and requests for future posts.
Next week we will take a deep dive into consent and capacity and tackle some more scenarios.