Case: Do not tell my wife
Ramratan was in tears. “How is it
possible doctor? We are expecting our son soon.
He will not have a father”. Ramratan
had seen you with vague aches, fever, weight loss
and cough with expectoration not
responsive to antibiotics for the past three months. He had a right mid zone
lung shadow on X-ray and the sputum was positive for AFB. On
being questioned, he had revealed that
he had unprotected sexual intercourse with multiple partners 3 years ago. “But
I stopped after I married Danno, doctor - I am faithful to her”.
An informed consent was obtained and
HIV screening test was ordered and it was positive.
A confirmatory test was subsequently
obtained and it was also positive. The CD4 count
was< 100. Ramratan had come to
discuss the results of his HIV test. After consoling him
and writing out prescriptions for TB
and HIV, you mention to him that he must bring his
wife for testing. “This is important,
Ramratan”, you add - “especially since she is
pregnant.”
“Absolutely not, sir!” he explosively
retorts. “That is not possible. I will be
humiliated. Danno will leave me and go.
I will never be able to see my son. I will become an outcast in our community.
I can’t live without my wife, doctor. I urge you, doctor -
don't do this. I forbid you…”
Patient confidentiality
Confidentiality is the right of an
individual to have personal, identifiable medical information kept private. It
means that personal and medical information given to a health care provider
will not be disclosed to others unless the individual has given specific
permission for such release. Confidentiality respects patient privacy and
autonomy.
Ethically, confidentiality is
derived from the principles of autonomy (the patient determines who shall know
his or her medical history) and fidelity (the fiduciary relationship of the
patient and physician requires trust and confidence). Confidentiality allows
the physicians to obtain all the information necessary to make a complete
diagnosis and motivate the patient to participate in therapy.
The
patient has the right to confidentiality. The physician should not reveal
confidential communications or information, without the consent of the patient,
unless provided for by law, for the need to protect the welfare of the
individual, or for public interest.The confidentiality of physician-patient encounters is a basic medical
ethic, reflected in the Hippocratic Oath.
What information is
confidential?
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. Confidentiality of Laboratory results must be
maintained at all times.
Give medical information
to patient first, Not the family/friends
The
doctor must convey medical information to the patient first. Without direct
instruction from the patient, the family/friends should never receive the
patient's confidential medical information. It is patient’s decision whether
he/she wants her family/friends to know about his/her medical condition. There
is a rare exception in the case of a patient with a psychiatric illnesses whom
to inform if the medical illness induce a suicidal attempt.
Release of information to
family, friends or colleagues
Confidentiality
also includes keeping a patient's medical information private even from his
friends and family unless the patient expressly consents that it is okay to
release the information to them. The patient may have a good relationship with
his family and friends but this is absolutely no excuse to assume that the
patient wants his/her medical information passed on to them. It may seem rude
and unreasonable but you must tell the patient's family members/friends that
you must ask your patient for permission before you release patient’s medical
information. The doctor must keep the medical information private from a
patient's co-workers as well.
Release of information to other doctors
Information
transfer between doctors involved in the care of patient is common. However,
the medical information about the patient can only be transferred if the
patient has signed a consent form requesting the transfer of information. The
patient must sign the consent form, not the health care providing doctor. The
referred doctor must demand for the signed consent form for release of
information by the patient from the referring doctor.
Release of information to the
governmental organizations and courts
If the
doctor receives a court order from authorized law personnel, that constitutes a
search warrant then the doctor must furnish the information that he/she
requests. If the investigator does not have a search warrant, then the doctor
must refuse him access to the patient’s files. The doctor is not under any
obligation to provide any information related to patient to third parties
unless it is at the request of the patient.
Exceptions to confidentiality:
The principle of confidentiality is never absolute
and has always been subject to limits in the interest of society, public
welfare, and the rights of other individuals. The patient’s right to
confidentiality is less important than another person’s right to safety. In
such cases the confidentiality can be broken in order to protect others. For
example, a mentally ill patient tells the psychiatrist that he/she intents to
harm someone. In such case, the psychiatrist must inform the law enforcement
and the potential victim. Other case where it is lawful to break the
confidentiality include partner notification for sexually transmitted diseases
such as syphilis and HIV infections.
Exceptions to patient confidentiality include the
following:
• Suicidal/homicidal patients
• Abuse (children, elderly, and/or prisoners)
• Duty to protect- State-specific laws
that sometimes allow physician to inform or somehow
protect potential Victim from harm.
• Epileptic patients and other impaired
automobile drivers.
• Reportable Diseases (eg, STDs,
hepatitis, food poisoning); physicians may have a duty to warn public
officials, who will then notify people at risk. Dangerous communicable
diseases, such as TB or Ebola, may require involuntary treatment.
Medical records
The doctor/health care facility physically owns the
medical record, but the information within it is the property of the patient.
The patient has an absolute right to free access to the information it contains
without providing any reason to the doctor/health care facility. The
information within medical records is covered by the same rules of
confidentiality. You cannot release the information within medical records
without patient’s consent to anyone. No one except those involved directly with
patient care has a right to access the information within patient’s medical
records. Doctors/health care facility cannot hold medical records as
“hostage" to compel a patient to pay medical bills. The need of
information to take care of patient is more important than the doctor’s right
to payment.
How to maintain confidentiality?
Doctors often violate ethics not because they mean
to, but because they are careless. As a matter of fact, they sometimes act with
good intentions.
·
Handle medical records as
confidential documents.
·
Do not leave patient information
and laboratory results unattended on printers, desks etc.
·
Protect information on Computer
screens by screen saver / time out functionalities.
·
Should a person call requesting
results and there is a question about the person’s identity, the requestor is
asked for his/her name and phone number where they can be called back.
·
Check that fax numbers are correct
before sending confidential information and laboratory results.
·
Patient information should never
be discussed with friends or relatives in a social setting.
·
Do not discuss with family or
friends patients details and if asked inform them that you are not permitted to
disclose any information. This includes patient names.
·
Do not discuss patient information
with the media.
·
Every health care organization
should have a policy that defines confidentiality and delineates who is
responsible for maintaining it. A good policy will state that every person who
works for the organization is responsible for ensuring patient confidentiality
and for reporting. policy violations. It also will state that managers are
responsible for implementing and enforcing the policy as it pertains to their
areas. Information about patients should be accessed or discussed only on a
need-to-know basis, according to job duties. To protect against lawsuits,
organizations should present the policy to new employees in orientation, and
have all employees sign a statement that they are aware of the policy.
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