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  1. 1. CONFIDENTIALITYWhere does the duty of confidentiality come from?What does the duty of confidentiality require?What kinds of disclosure are inappropriate?When can confidentiality be breached?What if a family member asks how the patient is doing?Confidentiality is one of the core tenets of medicalpractice. Yet daily physicians face challenges to this long-standing obligation to keep all information betweenphysician and patient private.Where does the duty of confidentiality come from?Patients share personal information with physicians. Youhave a duty as a physician to respect the patients trustand keep this information private. This requires thephysician to respect the patients privacy by restrictingaccess of others to that information. Furthermore, creatinga trusting environment by respecting patient privacy canencourage the patient to be as honest as possible duringthe course of the visit.
  2. 2. What does the duty of confidentiality require?The obligation of confidentiality both prohibits thephysician from disclosing information about the patientscase to other interested parties and encourages thephysician to take precautions with the information toensure that only authorized access occurs. Yet the contextof medical practice does constrain the physiciansobligation to protect patient confidentiality. In the courseof caring for patients, you will find yourself exchanginginformation about your patients with other physicians.These discussions are often critical for patient care andare an integral part of the learning experience in ateaching hospital. As such, they are justifiable so long asprecautions are taken to limit the ability of others to hearor see confidential information. Computerized patientrecords pose new and unique challenges to confidentiality.You should follow prescribed procedures for computeraccess and security as an added measure to protectpatient information.What kinds of disclosure are inappropriate?Inappropriate disclosure of information can occur inclinical settings. When pressed for time, the temptation todiscuss a case in the elevator may be great, but in thatsetting it is very difficult to keep others from hearing theinformation exchanges. Similarly, extra copies of handoutsfrom teaching conferences that contain identifiable
  3. 3. patients should be removed at the conclusion of thesession. The patients right to privacy is not beingrespected in these sorts of cases.When can confidentiality be breached?Confidentiality is not an absolute obligation. Situationsarise where the harm in maintaining confidentiality isgreater than the harm brought about by disclosingconfidential information. In general, two such situationsthat may give rise to exceptions exist. In each situation,you should ask - will lack of this specific information aboutthis patient put a specific person you can identify at highrisk of serious harm? Legal regulations exist that bothprotect and limit your patients right to privacy, notingspecific exceptions to that right. These exceptions follow.Exception 1:Concern for the safety of other specific personsOn the one hand, the 1974 Federal Privacy Act restrictsaccess to medical information and records. On the other,clinicians have a duty to protect identifiable individualsfrom any serious threat of harm if they have informationthat could prevent the harm. As mentioned above, thedetermining factor in justifying breaking confidentiality iswhether there is good reason to believe specificindividuals (or groups) are placed in serious dangerdepending on the medical information at hand. The most
  4. 4. famous case of this sort of exception is that of homicidalideation, when the patient shares a specific plan with aphysician or psychotherapist to harm a particularindividual. The court has required that traditional patientconfidentiality be breached in these sorts of cases.Exception 2:Concern for public welfareIn the most clear cut cases of limited confidentiality, youare required by state law to report certaincommunicable/infectious diseases to the public healthauthorities. In these cases, the duty to protect publichealth outweighs the duty to maintain a patientsconfidence. From a legal perspective, the State has aninterest in protecting public health that outweighsindividual liberties in certain cases. In particular,reportable diseases in Washington State include (but arenot limited to): AIDS and Class IV HIV, hepatitis A and B,measles, rabies, tetanus, and tuberculosis. Suspectedcases of child, dependent adult, and elder abuse arereportable, as are gunshot wounds. Local municipal codeand institutional policies can vary regarding what isreportable and standards of evidence required. It is bestto clarify institutional policy when arriving at a new site.
  5. 5. What if a family member asks how the patient isdoing?While there may be cases where the physician feelscompelled to share information regarding the patientshealth and prognosis with, for instance, the patientsinquiring spouse, without explicit permission from thepatient it is generally unjustifiable to do so. Except incases where the spouse is at specific risk of harm directlyrelated to the diagnosis, it remains the patients, ratherthan the physicians, obligation to inform the spouse.