Detoxicol

SDLS 2008
Medicine for the intoxicated
Subject: Bioethics Lecture Date: July 15, 2005
Topic: Confidentiality Transcriber(s): JC Oca & Karen
Lecturer: Melchor Frias M.D. No. of pages: 5

CONFIDENTIALITY

 concerned with keeping secrets

 difficult to do when confronted with critical problem

Justification of the required moral practice of keeping secrets

 human dignity
 autonomy
 right to know the truth

Secret
 knowledge which a person has the right to conceal
 if revealed will affect the one who revealed the secret, the one who has the secret or it will affect others
 obligation to keep secrets arises from the fact that harm will follow if the particular knowledge is revealed unless
there are reasons not to conceal it
 in one way or another, secrets are concealed for some reason and will cause harm if kept
 there are secrets we are obliged to keep

**Keeping a secret is avoiding harm, especially in a patient-doctor relationship

Obligatory Secret
 the obligation to keep a secret arises from the fact harm will follow if a particular knowledge is revealed

Three types:
• Natural secret
o not always medical in nature
• Promised secret
• Professional secret

NATURAL SECRET

 the information involved is by its nature harmful if revealed

 we don’t make promises

Avoid harm
 a universal rule in medical practice
 as medical practitioners it is our duty not to harm our patients
 Example
• to keep our patients diagnosis confidential
 if harm follows after the revelation of the secret
• then it must be kept instead
 once a patient enters the hospital, confidentiality is considered part of the consent
 if reported, secret should be kept between you and your preceptor
 obligation exists no matter how a person gets information
 Examples
• private peculiarities of the person
• hospitalization name of the patient
• consultation diagnosis

Principles:
 an obligation to avoid harming others unless there is proportionate reason for risking or permitting the harm
• use proportionality to justify revelation of secrets
• proportionality should be applied in breaking confidentiality
  sometimes harm which comes from keeping natural secret outweighs harm caused when secret is revealed
• patient with AIDS who attempt to give blood
o there is a stigma involved when this is revealed
• persons with infectious disease
• if concealing equals harm, then reveal the secret

 the form of treatment the patient yet to receive, and anything under the confinement and charts should be kept
confidential

Promised Secret

 knowledge that has been promised to be concealed

• like taking an oath

 concerned with keeping and breaking promises

 promise makes nature of information more sensitive

 when broken, the harm caused is more than that of its natural state

 can either be in verbal or in oath

 trickier than natural secret

 can break communication and social relationship

***Socialization depends on the ability of the person to keep promises.

Principles:
 generally the promise has been exacted because the matter is also a natural secret
• in this case the nature of the secret makes it stricter

 the evil of revealing promised secrets arises from the harmful effects of breaking promises
• breaks down communication and social relationship

 the promised secret may be revealed if the good to be attained affects the evil that results from the
broken promise as well as, from the nature of the information
• consequences are much worst than natural promises when you break it
• use proportionality principle – would you risk breaking a promise about sensitive information

Proportionality principle
 justifies revelation of both natural and promised secrets
 weighing out the good and the bad
 if the harm from concealing a secret outweighs the harm from revealing the secret, revelation of the
secret can be justified
• weigh the good and bad effects, if it is good, you can reveal it

Professional Secret

 knowledge which, if revealed, will harm only the professional’s client, but will do serious harm to the
profession and to the society which depends on the profession for important services

 most important and of concern to the physicians

 in many cases, this is recognized by law so that a professional would not have to reveal “privileged
communication” even in court
• Statutory Immunity
o protects physicians from testifying
o we may not testify treatment of patient in court due to the:
 nature of secret
 implied promise
 good of profession patients may not trust you

 establishes patient and physician relationship

 most seriously deal with secret because of (yes, eto nanaman po ):
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 • nature of knowledge
• implied promise
• good of profession and society

 affect the profession as a whole

• the society depends on medical profession for health services
• if the medical profession could not be trusted, then the society would not seek health sciences

 recognized by the law so that a professional would not reveal “privileged communication” even in the court
• a physician cannot just disclose information to anyone regarding his patient’s chart, unless he gets the
consent/permission of his patient
• interns/clerks/residents have no right to look into the patient’s chart, unless there is a “need to know”
o people who are allowed to look at the patient’s chart are those:
 permitted by the patient
 directly involved in diagnosis and treatment

Principles:
 importance of this secret in health care is best seen by contemplating the consequences : should patient lose
their faith in the confidentiality of their dealings with health care system
• yung STD case sa U.S….nawalan ng trust yung mga teenagers sa mga physician
because of a law na nag-rerequire sa kanila to report STD cases to their parents…
• patient loses faith in doctors  patient will not consult to any doctor anymore
o STD cases are legal exemptions to confidentiality

 the condition of the patient’s body is private and is shared only with those he/she
chooses to help him/her, but not with anyone else
• when a patient chooses you to touch his body then he is giving you his trust

 there is an implied promise to keep the secret by virtue of profession

• patient-physician relationship
o implies a promise secrecy
o “implied promise”
o established when an M.D. TREATS the patient
 not yet in consultation or patient diagnosis
o patient-doctor relationship starts when the doctor begins to treat the patient

Why should a professional secret be kept? (once again…kulit ano )

 nature of knowledge
 implied promise
 good of the profession

EXCEPTIONS OF CONFIDENTIALITY

1. exception commanded by statute law

• in each case, the law presumes that the public good demands an exception and
so outweighs the harm of revelation
o gunshot wounds, car accidents
o child abuse cases
o medico-legal cases
o birth defects/deformities, illegitimate persons
o communicable diseases
o acute poisoning
o vehicular accidents
o industrial accidents
o drug addiction

• it is also assumed that the patient knows that these cases

are not covered by the implied promise of the patient-provider relationship

2. those arising from legal precedent

• those arising from previous decisions
• the problem here is that there are different courts thus different opinions
• therefore, general rule must be followed: it is reasonable to accept the ethical correctness of courts
• confidentiality may be overridden because this has implication tot safety of the patients

3. those arising from a particular patient-provider relationship

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 • in industrial and military companies pre-employment physical exam, the physician is required to
report any abnormalities of the employee that are work related
o M.D. should be loyal both to the patient and the employer
 but loyalty is first provided to the patient

o no true relationship (kasi P.E. pa lang, wla pang treatment)

o patient-M.D. dilemma: whether to present information to the employer

 as long as the patient understand that he is not exempted from confidentiality, then no
ethical law are broken
 if it can affect the work of the patient, them M.D. should tell the employer
 confidentially may be waived if required by the law
 not all information like medical history may be revealed…only those pertinent information
to work may be revealed

***As long as the patient understands that he is not fully protected by confidentiality, no serious ethical problems may
arise
Patient  doctor  employer or officer

4. those due to proportionate system

• apply the principle of PROPORTIONALITY
o weighing risk and benefits

o consider a public good that must be at stake before revealing the information; if general public at
state justify revelation of information

o one is not allowed to reveal the diagnosis regarding illness of the patient without the permission
of the patient

o in general the physician is not allowed to tell the spouse about the illness of the patient without
the patient’s consent
 patient with AIDS – if patient refuses to tell his/her parents, the physician should
tell the patient that he will be the one to the parents
 it you tell then patient-physician and husband-wife relationship will be broken

o weigh the risks and benefits regarding revealing the information

o it is reasonable to say that presumption be in favor with confidentiality

Other Issues Regarding Confidentiality

Family
 if a patient is incompetent and family asks for the information
• M.D. can reveal some
 revealing a certain information of the patient does not establish trust and destroys patient-doctor relationship
 always ask a competent patient first before revealing any information
 information should be revealed to families if patient is incompetent
• competent patient always assumes that there is promise of confidentiality
o revealing information does not promote trust
 physician should always consider the patient first
 example: if patient is diagnosed to have cancer
 physician should reveal the information to the patient first, but if and when the doctor
thinks that the patient may not take the information, withhold the information first
• relatives can act as surrogate to purposes of getting informed consent for the physician to be able
to reveal information

Media
 media personalities and/or public figures still retain their rights for privacy
 in such cases, under public pressures and/or demands, the involved patient (personality) should be sought for
revelation and not the health care providers
 M.D. can attend press conferences and can reveal information but it should be summarized and not detailed
 information can only be divulged if permission is granted by the patient
• politicians and actors

Hospital records
 any records regarding patient’s information should be kept confidential

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 • 3rd year students required to submit chart review
• for clerks and residents, implicitly can get information for research
 use only summarized data (mean, media, mode) without identification
 number of people who will be looking at the chart should be kept at minimum (in short, yung may kinalaman
lang sa case ng patient)
 done retrospectively
• patient has already been treated and no longer stays in the hospital
 a summary data with no identification should be used in publishing a research

Health Insurance
 weakens confidentiality and may result to harmful consequences
 confidentiality and 3rd party payers refer to involvement with company health insurance (policies are involved
wherein information are revealed)
 computerization of health care information represents a potential for the harm of the patients
 information can be used against the patient (socio-political impact)

Public good
 depends on the legislation necessary for revelation
 society needs to speak through specific legislation
 examples:
• SARS patients are asked to quarantine themselves, but if they don’t follow…the public should be
warned regarding the case
• AIDS patients – public wants to reveal patients with AIDS because they want to protect themselves
 there are no laws of breaking confidentiality about AIDS because most patient are quarantined (except Magic
Johnson)

Confidentiality and Health care Professional

 a health care professional has a right to consult other health care professionals in an effort to help the patient
 a physician not involved professionally in a patient has no right to look at the chart of the patient
 residents, interns and other students in a teaching hospital are not free to look at the patient’s chart unless
they are DIRECTLY INVOLVED in the care of the particular patient.

Exceptions in the case of children and adolescents

 parents as principal guardians have the right to know also by proportionate reasons
 yet confidentiality is still preserved due to public health reasons
• STD
 give counseling to the patient
 generally, loyalty to the patient first, the family is only secondary

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Sori guys kung ngayon ko lang ito nailabas… Anyway, goodluck sa lahat ng evals… Ganbatte!!!!

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