confidentiality toby l. schonfeld, ph.d. department of preventive and societal medicine...

ConfidentialityConfidentiality

Toby L. Schonfeld, Ph.D.Toby L. Schonfeld, Ph.D.Department of Preventive and Societal Department of Preventive and Societal

MedicineMedicinetschonfeld@unmc.edutschonfeld@unmc.edu

What’s at stakeWhat’s at stake

What confidentiality isWhat confidentiality is

How it is promoted by professionsHow it is promoted by professions

Why confidentiality is importantWhy confidentiality is important

Justified instances of disclosureJustified instances of disclosure

Types of sanctionsTypes of sanctions

How do we navigate difficult cases?How do we navigate difficult cases?

Confidentiality is...Confidentiality is...

““A socially publicizable and enforceable A socially publicizable and enforceable pledge to keep secret or hold in pledge to keep secret or hold in confidence any information about the confidence any information about the client which is gained by the professional client which is gained by the professional during the normal course of client-during the normal course of client-professional interactions.”professional interactions.”– Rem B. Edwards, “Confidentiality and the Rem B. Edwards, “Confidentiality and the

Professions,” Bioethics (.....)Professions,” Bioethics (.....)

Specific Statements ofSpecific Statements ofProfessional PromotionProfessional Promotion

Nuclear Medicine Code of Ethics Nuclear Medicine Code of Ethics

Principle III:Principle III:““The Nuclear Medicine Technologist will The Nuclear Medicine Technologist will maintain strict patient confidentiality in maintain strict patient confidentiality in accordance with state and federal accordance with state and federal regulations.” regulations.”

Specific Statements of Specific Statements of Professional PromotionProfessional Promotion

American Dietetic Association American Dietetic Association Code of EthicsCode of Ethics

Principle IV:Principle IV:

““The dietetic practitioner maintains The dietetic practitioner maintains confidentiality of information.confidentiality of information. “ “

American Society of Radiologic American Society of Radiologic TechnologistsTechnologists

““The radiologic technologist respects The radiologic technologist respects confidences entrusted in the course of confidences entrusted in the course of professional practice, respects the professional practice, respects the patient's right to privacy and reveals patient's right to privacy and reveals confidential information only as required confidential information only as required by law or to protect the welfare of the by law or to protect the welfare of the individual or the community. “individual or the community. “

Why keep patient information Why keep patient information confidential?confidential?

Fundamental human values

Rules of Confidentiality

Professional behavior

Why keep patient information confidential? Why keep patient information confidential? (1) Privacy(1) Privacy

Information about ourselves we do not Information about ourselves we do not want disclosed to otherswant disclosed to others– General:General:

Physical factsPhysical facts

Mental factsMental facts

Behavioral factsBehavioral facts

– SpecificSpecific

Risks associated with the violation of Risks associated with the violation of privacyprivacy

Why keep patient information confidential? Why keep patient information confidential? (2) Social Status(2) Social Status

Confidentiality affirms and protects the Confidentiality affirms and protects the social status of the clientsocial status of the client– Marginalized groupsMarginalized groups– Stigmatizing conditionsStigmatizing conditions– Community membersCommunity members

Why keep patient information confidential? Why keep patient information confidential? (3) Economic Advantage(3) Economic Advantage

Confidentiality is economically Confidentiality is economically advantageous to the patientadvantageous to the patient– Economic stigmatizationEconomic stigmatization

Why keep patient information confidential? Why keep patient information confidential? (4) Open Communication(4) Open Communication

Confidentiality promotes open Confidentiality promotes open communication between provider-patientcommunication between provider-patient– Encourages patients to disclose intimate Encourages patients to disclose intimate

detailsdetails– Violations of confidentiality cause patients to Violations of confidentiality cause patients to

withhold essential informationwithhold essential information

Why keep patient information confidential? Why keep patient information confidential? (5) Seeking help(5) Seeking help

Confidentiality encourages patients to Confidentiality encourages patients to seek professional help.seek professional help.– Open communication first requires the patient Open communication first requires the patient

to come to the officeto come to the office– Studies show that seeking help is a Studies show that seeking help is a

cost/benefit analysis: professional service cost/benefit analysis: professional service gains vs. confidentiality lossesgains vs. confidentiality losses

Why keep patient information confidential? Why keep patient information confidential? (6) Trust(6) Trust

Trust: confidence that we can depend on Trust: confidence that we can depend on the competence, integrity, support, care, the competence, integrity, support, care, and concern of anotherand concern of another

– ABIM Charter: commitment to professional ABIM Charter: commitment to professional competencecompetence

– Violation of trust results in contempt, deep Violation of trust results in contempt, deep alienation, suspicionalienation, suspicion

Why keep patient information confidential? Why keep patient information confidential? (7) Promotes autonomy(7) Promotes autonomy

Autonomy: capacity for making decisionsAutonomy: capacity for making decisions

HIPAA: information is in the control of the HIPAA: information is in the control of the patientpatient

Principle of patient autonomy: CharterPrinciple of patient autonomy: Charter

DisclosureDisclosure

““Need to know” information Need to know” information

Sometimes we have other values that will Sometimes we have other values that will conflict with our value of confidentialityconflict with our value of confidentiality

DisclosureDisclosure

Legitimate breaches of confidentiality must Legitimate breaches of confidentiality must consider the following points: consider the following points: – There is no less costly way of promoting the There is no less costly way of promoting the

competing valuescompeting values– The conflicting value will be significantly The conflicting value will be significantly

advanced by violating confidentialityadvanced by violating confidentiality– Competing value is more important than the 7 Competing value is more important than the 7

confidentiality valuesconfidentiality values

Specifics of disclosureSpecifics of disclosure

When are breaches acceptable or When are breaches acceptable or required?required?– Violent wound reportsViolent wound reports– Suspicion of abuse or neglectSuspicion of abuse or neglect– Danger to self or othersDanger to self or others– Communicable diseasesCommunicable diseases

SanctionsSanctions

Moral sanction: conscienceMoral sanction: conscience

Social sanction: public opinionSocial sanction: public opinion

Legal sanction: positive law and means of Legal sanction: positive law and means of enforcementenforcement

Now back to the case...Now back to the case...

OptionsOptions

Recommend that Al inform his partnerRecommend that Al inform his partnerFacilitation of disclosureFacilitation of disclosureRisk reductionRisk reductionExplore Al’s valuesExplore Al’s valuesCall the health departmentCall the health departmentSet time limit for Al’s disclosure to partnerSet time limit for Al’s disclosure to partnerDismiss Al from your practiceDismiss Al from your practiceDisclose risk to Al’s partnerDisclose risk to Al’s partner

Competing valuesCompeting values

Privacy rights of Al vs. autonomy rights of Privacy rights of Al vs. autonomy rights of partnerpartner

Autonomy rights of partner vs. risk to Autonomy rights of partner vs. risk to physician-patient relationshipphysician-patient relationship

Responsibility to patient vs. responsibility Responsibility to patient vs. responsibility to publicto public

Criteria for breaching confidentialityCriteria for breaching confidentiality

Is the burden met here?Is the burden met here?– Alternatives to disclosureAlternatives to disclosure– Which “conflicting values” will be advanced?Which “conflicting values” will be advanced?– Are these values more important than the 7 Are these values more important than the 7

fundamental values?fundamental values?