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Abstract

The law views confidentiality as a balance of public interests rather than a “right” afforded to the individual, and this potentially conflicts with the medical definition. Rarely, it is compulsory to disclose confidential information. Instances include disclosure to protect others, disclosure of information to the police, disclosure of notifiable diseases, and disclosure of information about a patient’s fitness to drive.

Introduction

The morality is an essential requirement for any profession, particularly medical field. Western and Eastern medical ethical schemes derived from Hippocratic Oath [1]. Thomas Percival set up the English Constitution for the doctor of medical ethics in 1794; it had provided a standard of conduct [2]. In 1980 was newcomer Constitution of the American Medical Association of important seven items, while the upgraded version of the 2001 nine important items [3].

Six values that commonly should be applied in any medical ethical dilemma, these values do not give perfect solutions as to how grip a particular ethical dilemma, but provide a useful outline for understanding conflicts (Beneficence; Non-maleficence; Autonomy; Justice; Dignity; Truthfulness, honesty, and informed consent) [4,5].

The confidentiality is a foundation stone of trusted therapeutic relationship between a patient and physicians and it can be clearly raised by the patient requesting that information provided be reserved confidential, moreover there is an inherent obligation on the part of physicians, and expectation on the part of patients, that information will kept confidentially. It is recognized, however, that confidentiality is not absolute, in the Bahrain, Decree law no. 7, article 126 (1989), this has meant that confidentiality can be breached when legally required or when there is a significant risk of serious harm befalling another person if confidentiality is maintained [6].

Confidentiality in the medical setting refers to “the principle of keeping secure and secret from others, information given by or about an individual in the course of a professional relationship” [7] and it is the right of every patient, even after death [8].

Breaches of confidentiality in daily primary care practice do not follow into the standard scenario of disclosure for sensitive clinical information; many may be unintentional or related to lack of knowledge of the relevant legal and professional ethical requirements. A clear understanding of the duty of confidentiality and how it is applied in the daily primary care practice is an important competence for all GPs [9].

Around a third of the calls received by the Medical Protection Society from doctors are related to confidentiality, particularly in general practice [10].

Case study

25 years old, foreigner housemaid female complaining from delay menses for last 2 month, worried that she might be pregnant. A pregnancy test is positive and examination confirms a pregnancy of about 10 weeks. The physician was informed police for reporting illegal pregnancy from her boyfriend.

Case discussion

The General Medical Council (GMC) has the following statement: Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to seek medical attention or to give doctors the information they need in order to provide good care. But appropriate information shar­ing is essential to the efficient provision of safe, ef­fective care, both for the individual patient and for the wider community of patients [8] (GMC, 2009a).

Maintaining confidentiality is part of the “good faith” that exists between doctor and patient [11]. Ignoring patients’ rights to confidentiality would lose their trust, and might prevent people from seeking help when needed. Confidentiality preserves individual dignity, prevents information misuse, and protects autonomous decision making by the patient [12].

If a patient does not trust her physician, she may not seek help when she needs it or may not divulge significant information that would support her diagnosis [9] the consequences of breach patient confidentiality definitely will harm both the individual patient and overall trust in the medical profession [12]. Therefore, physicians should obey the ethical principles of preventing harm and benefiting patients, the physician duty of confidentiality has a sound ethical foundation, unless pregnancy was happened in under age group (≤ 16 years)by checking “Gillick competence” [13] or there was history of sexual abuse by the sponsor or their family [14].

An autonomous individual has the right to make consent whenever possible about who should have the access to her condition, even when information is shared for the benefit of the patient’s or sponsor's care. Eventually the clinician who shares any patient information with others, without the patient’s consent, does not respect the patient’s autonomy and will therefore have behaved in a morally questionable way [10] (GMC, 2009a).

However, the duty of confidentiality is not absolute and there are many ethical justifications for breaching confidentiality in our case study because of harm to the sponsor's interest. Breaching confidentiality while consider both benefit and harm, to all partners (patient/ sponsor/society); it is legitimate to constrain personal freedom if exercising that freedom will result in harm to others, even patient’s right to determine how personal information is shared with others is constrained by an obligation not to harm others.

Breach of patient's confidentiality should be considered in certain situations

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If there are legal requirements to disclose information of notification cases due to presence of specific infectious diseases, or asking by various regulatory bodies or by a judge or presiding officer of a court, but  not disclose personal information to a third party such as a solicitor or police officer without the patient’s express their consent [8,10,15].

However, physician should always take patient's approval consent for information disclosure, while it is not compulsory, in certain conditions(e.g. sharing patient's information within the healthcare team, the patient came in an emergency situation, request from patient’s insurer, and in patient's medical certificate/report) [8,10,15].

Nonetheless, in general the disclosures patient's confidentiality to protect public/ patient/ partner from risks of serious harm (e.g. serious communicable diseases or risk of death from serious crime, victim of neglect or abuse) or to facilitate medical research, education or other secondary uses of information that will benefit society over time [8,10,15].

Sometimes physician was urge to divulge patient's confidentiality, if patient have lack of mental capacity to consent (e.g. lack of capacity is permanent or temporary), so physician should share the important information with a patient’s partner, careers, relatives or friends.

As an alternative, physician should divulge significant information promptly to appropriate responsible person or authority if the patient is being a victim of neglect or abuse (physical, sexual or emotional abuse) [8,10,15].

Physician duty of confidentiality should continue even after patient has died, except in certain circumstances (to write death certificates, when a parent asks for information about the circumstances and causes of a child’s death) [8,10,15].

Physician has a duty to inform the police immediately, when patient is brought with history or suspicion of gunshot or knife wounds, suicidal attempt, prepared to use weapons, domestic violence and suspicion of crime/assault/ road traffic accident [3,8,10,16].

The rape law was arranged in Bahrain's legislative Decree-Law No. 15/1976 version of the Penal Code on the show article 344 – that any person has to be punished by imprisonment for a victim is not reach sixteenth under age, or without patient consent of victim at any adult age, that was not adequate in our case study [16].

In Bahrain, we need more legislative laws on how should physician maintain and when physician should reveal the patient confidentiality and when to have a legal obligation to inform the General Directorate of Traffic Office; if the patient is diagnosed with a medical condition that could impairs fitness to drive [8,10,15].

Key points

• 1. Recognizing and maintaining a duty of confidentiality can bring particular challenges in the context of primary care.
• 2. GPs need to be aware of their statutory obligations to disclose information and the limits of this obligation.
• 3. When there is a significant risk of serious harm to others if information is not shared, the duty to protect or warn may override the duty of confidentiality.
• 4. The principle of respect for autonomy requires that GPs inform patients in situations where they consider it necessary to disclose information without the patient’s consent.
• 5. Information about the kinds of information sharing that may take place in primary care should be available to patients in GP clinics.

Recommendation

• 6. To formulated new practical goals for family medicine ethics curricula.
• 7. To set tools, how does tutor assist teaching programs and evaluate ethical competencies?
• 8. To have primary care handbook presents an “ethics primer” for family physicians.
• 9. To have user-friendly, valid, and reliable guidelines with common primary care ethical dilemma discussion.
• 10. To have more legislative laws on how should physician maintain and when physician should reveal the patient confidentiality?

Potential conflicts of interest

None

Competing interest

None

Sponsorship

None

References

1. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html.
2. http://wikipedia.atpedia.com/en/articles/m/e/d/Medical_ethics.html.
3. Percival, Thomas. Medical ethics, 49-57 esp section 8 pg.52.
4. Shanawani H, Lowe KN (2005) Is Greenacres (SNF) the place to be? Virtual Mentor [serial on the Internet]. 2005 [cited 2005 July 24]; 7 (7).
5. Veatch RM (2000) The basics of bioethics. 2nd ed. Upper Saddle River (NJ): Prentice Hall.
6. http://www.bahrainlaw.net/post1295.html.

1. BMA (1999) Confidentiality and disclosure of health information.
2. General Medical Council (2009) Confidentiality: protecting and providing information 2009.
3. Slowther A (2010) Confidentiality in primary care: ethical and legal considerations.  InnovAiT3: 753–759.
4. General Medical Council. Confidentiality (2009a) London: GMC. Accessed via www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp. [last date accessed 28.10.2014].
5. O’Neill O (2002) Licence to decieve. Reith lectures.
6. Souhami R, Chalmers S, Collins R, Luker K, Newton J, Silman A, et al. (2006)Personal data for the public good: using health information in medical research. London: The Academy of Medical Sciences.
7. (1984) Gillickv West Norfolk and Wisbech Area Health Authority. All Engl Law Rep1985: 533-59. [Crossref]
8. Ablashi DV, Zompetta C, Lease C, Josephs SF, Balachandra N, Komaroff AL, et al. (1991) Human herpesvirus 6 (HHV6) and chronic fatigue syndrome (CFS). Can Dis Wkly Rep17(suppl 1E):33-40. [Crossref]
9. http://ministryofethics.co.uk/index.php?p=6&q=7.
10. http://www.legalaffairs.gov.bh/LegislationSearchDetails.aspx?id=4069.