Consent and Confidentiality in psychiatric practice: an Egyptian perspective

1. IT Y
& IAL
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H IEN IA
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D E A
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2. PRE TEST
True or False :
3.Legally, consent is only valid when written.
4.Mental capacity is constant in all situations.
5.You can hide information from the patient if these information would harm him.
6.You personal experience is the only key to patient’s best interest.
7.Once the patient agree on a procedure, he have to go through it till the end.
8.You can breach patient’s confidentiality if these information would safe another
person.
9.Confidentiality of psychiatric patients is protected by Egyptian laws

3. GOALS OF THE LECTURE
• Why is consent legally necessary?
• What are the essentials of valid consent?
• How do you assess Mental Capacity?
• Why is confidentiality important?
• When can you breach confidentiality?

4. INTRODUCTION
Mohr v. Williams (1905), the plaintiff consented to
an operation on her right ear. When she was
anaesthetized, her surgeon made the decision to
operate on her left ear instead, because this was
found to be more seriously diseased.
Despite no harm having occurred to the patient, a
claim in battery was successful as the patient had
only consented to surgery on her right ear.

5. CONSENT
• The agreement to a treatment or procedure
• Does not have to be given in writing; it can be given orally
or even implied from the circumstances
e.g. holding an arm out for an injection, nodding the head
• Consent is limited to the procedures which the patient has
been informed of and agreed to. Except in an emergency it
cannot be exceeded to include other procedures
• Consent can be withdrawn prior to the procedure

6. ESSENTIALS ELEMENTS OF CONSENT
• The patient must be competent to give consent.
• It must be voluntary, and not coerced.
• The patient must be provided with information
about the procedure

7. COMPETENCE
(MENTAL CAPACITY)
The Mental Capacity Act 2005 (MCA) states that a person lacks
capacity if they cannot do one or more of the following:
•Understand the information relevant to the decision
•Retain that information
•Use or weigh that information as part of the process of making
the decision
•Communicate the decision (whether by talking, using sign
language or any other means).

8. COMPETENCE
(MENTAL CAPACITY)
 Capacity can evolve and fluctuate over time, and treatment should
be postponed if capacity can be restored.
 It is task specific – a person may have capacity to make a particular
decision but lack capacity for other more complex decisions.
 Before it is concluded that someone lacks capacity to make a
decision all possible steps should be given to help them to reach the
decision
 Consider treatment options which are least restrictive of the
person’s rights or future choices and which promote the greatest
freedom

9. COMPETENCE
(MENTAL CAPACITY)
Lasting power of attorney (LPA)
is a legal document which allows a person (donor) to appoint someone to take
decisions (attorney) for him in the event of loss of capacity
Independent mental capacity advocate (IMCAs)
independent advocates who represent the views of vulnerable people lacking
capacity to make important decisions about serious medical treatment when
there are no family members or friends who can be consulted

10. COMPETENCE
(MENTAL CAPACITY)
Ms. B v. NHS Hospital Trust (2002)
Ms. B’, a 43-year-old paralyzed woman who had been kept alive on a ventilator
for 11 months and now wished to be allowed to die. When the hospital trust
looking after her refused to switch the ventilator off, arguing she could not make
a truly informed decision until she had tried special rehabilitation to improve her
condition, Ms. B took the matter to court. In a hearing convened at her bedside, it
was held that not only was she competent to make her own decisions but that,
moreover, the hospital trust had been in breach of the Human Rights Act for
failing to accede to her wishes

11. COMPETENCE
(MENTAL CAPACITY)
‘It is most important that those considering the issue should not confuse the
question of mental capacity with the nature of the decision made by the patient,
however grave the consequences.
The view of the patient may reflect a difference in values rather than an absence
of competence and the assessment of capacity should be approached with this
firmly in mind.’

12. VOLUNTARY DECISION MAKING
It is for the patient, not the doctor, to determine what is in the patient's own
best interests. Nonetheless, you may wish to recommend a treatment or a
course of action to patients, but you must not put pressure on patients to accept
your advice. In discussions with patients, you should:
– Give a balanced view of the options;
– Explain the need for informed consent.
– Declare any conflict of interests
You should not make assumptions about patients' views

13. VOLUNTARY DECISION MAKING
Patients who are detained by the police, or are in
prison, and those detained under the provisions of
any mental health legislation may be particularly
vulnerable. Where such patients have a right to
decline treatment you should do your best to ensure
that they know this, and are able to exercise this right.

14. THE INFORMATION PATIENTS SHOULD KNOW
 details of the diagnosis, and prognosis, and the likely prognosis if the condition is left untreated;
 uncertainties about the diagnosis including options for further investigation prior to treatment;
 options for treatment or management of the condition, including the option not to treat;
 the purpose of a proposed investigation or treatment; details of the procedures or therapies involved, including subsidiary
treatment such as methods of pain relief; how the patient should prepare for the procedure; and details of what the patient
might experience during or after the procedure including common and serious side effects;
 for each option, explanations of the likely benefits and the probabilities of success; and discussion of any serious or
frequently occurring risks, and of any lifestyle changes which may be caused by, or necessitated by, the treatment;
 advice about whether a proposed treatment is experimental;
 how and when the patient's condition and any side effects will be monitored or re-assessed;
 the name of the doctor who will have overall responsibility for the treatment and, where appropriate, names of the senior
members of his or her team;
 whether doctors in training will be involved, and the extent to which students may be involved in an investigation or
treatment;
 a reminder that patients can change their minds about a decision at any time;
 a reminder that patients have a right to seek a second opinion;
 where applicable, details of costs or charges which the patient may have to meet.

15. THE INFORMATION PATIENTS SHOULD KNOW
•You should not withhold information necessary for decision making unless you
judge that disclosure of some relevant information would cause the patient
serious harm. In this context serious harm does not mean the patient would
become upset, or decide to refuse treatment.
•Allow patients sufficient time to reflect, before and after making a decision,
especially where the information is complex or the severity of the risks is great.
Where patients have difficulty understanding information, or there is a lot of
information to absorb, it may be appropriate to provide it in manageable
amounts, with appropriate written or other back-up material, over a period of
time, or to repeat it;

16. ‫تطبيقات من القانون المصرى‬
‫القانون المدنى‬
‫الرضاء‬
‫(مادة ) ٠٩‬
‫١( التعبير عن الرادة يكون باللفظ وبالكتابة وبالشارة المتداولة عر ًا، كما يكون باتخاذ موقف ل تدع ظروف‬
‫ف‬
‫الحال شك ً في دللته على حقيقة المقصود‬
‫ا‬
‫٢( ويجوز أن يكون التعبير عن الرادة ضمن ًا، إذا لم ينص القانون أو يتفق الطرفان على أن يكون صريح‬
‫ي‬
‫الهلية‬
‫(مادة ) ٥٤‬
‫١( ل يكون أهل لمباشرة حقوقه المدنية من كان فاقد التمييز لصغر في السن أو‬
‫عته أو جنون‬
‫.٢( وكل من لم يبلغ السابعة يعتبر فاق ًا للتمييز‬
‫د‬

17. ‫تطبيقات من القانون المصرى‬
‫قانون الحوال الشخصية الجديد‬
‫قانون رقم 1 لسنة 0002‬
‫مادة )82(‬
‫علي الطباء المعالجين ومديري المستشفيات والمصحات علي حسب الحوال‬
‫ابلغ النيابة العامة عن حالت فقد الهلية الناشئة عن عاهة عقلية بمجرد ثبوت‬
‫ذلك لديهم وعلي المختصين بالسلطات الدارية ابلغ النيابة العامة متى تبين‬
‫لهم أثناء تأدية عملهم حالة من حالت فقد الهلية على النحو المشار إليه فى‬
‫الفقرة السابقة‬

18. ‫تطبيقات من القانون المصرى‬
‫قانون رعاية المريض النفسى‬
‫رقم 17 لسة 9002‬
‫إلزامى‬ ‫إرادى‬ ‫الحالة‬
‫مادة )21(,)31(,)41(,)71(,)81(,)42(‬ ‫مادة )01(‬ ‫دخول‬
‫مادة )11(,)51(,)91(,)52(‬ ‫مادة )02(‬ ‫حجز‬
‫مادة )92(,)33(‬ ‫مادة )72(‬ ‫علج‬
‫مـــــــــــــــــــــــــــــــــــــــــــــــادة )63(‬ ‫حقوق‬

20. INTRODUCTION NO 2
• Dr. Hamdy A. Farag , General Manager of Salma Hospital filed a report
against An elected parliament member, accusing him that Mr. A. El
Belkemy wrongfully claimed being attacked, while he had undergone
surgery, believed to be a nose job.
• Dr Hamdy rationalize his actions for the excessive lying of the parliament
member in the media, yet he confirms that Mr. Belkemy told him not to tell
anyone about the operation.
• The member had resigned from his party & the parliament.

21. CONFIDENTIALITY
The obligation to keep safe and secret health information provided in the
course of a professional relationship
Maintaining patient confidentiality is necessary to ensure that patients trust
doctors with personal and sensitive information

22. DATA PROTECTION ACT 1998
The eight principles of good practice
Anyone processing personal information must comply with eight enforceable principles of
good information handling practice.
These say that data must be:
1. fairly and lawfully processed
2. processed for limited purposes
3. adequate, relevant and not excessive
4. accurate and up to date
5. not kept longer than necessary
6. processed in accordance with the individual’s rights
7. secure
8. not transferred to countries outside European Economic area unless country has
adequate protection for the individual

23. THE CALDICOTT GUARDIAN
Acting as the ‘conscience’ of an organization, the Guardian should also actively
support work to facilitate and enable information sharing, and advise on
options for lawful and ethical processing of information as required

24. DISCLOSURE OF INFORMATION
The duty of confidentiality is an important cornerstone
of the provision of medical care but it is not absolute…
Disclosure of Medical data can occur in one or more of
the following conditions
•Having the explicit consent of the individual
•Being required by law to process the information for
employment purposes
•Needing to process the information in order to protect
the vital interests of the individual or another person
•Dealing with the administration of justice or legal
proceedings

25. ‫تطبيقات من القانون المصرى‬
‫العلن الدستورى‬
‫المادة 11‬
‫حياة المواطنين الخاصة حرمة يحميها القانون‬
‫وللمراسلت البريدية والبرقية والمحادثات التليفونية وغيرها من وسائل التصال حرمة, وسريتها مكفولة ول تجوز‬
‫.مصادرتها أو الطلع عليها أو رقابتها إل بأمر قضائي مسبب ولمدة محددة ووفقا لحكام القانون‬

26. ‫تطبيقات من القانون المصرى‬
‫قانون رعاية المريض النفسى‬
‫رقم 17 لسة 9002‬
‫مــادة )63( :‬
‫بند )81( :‬
‫حماية سرية المعلومات التي تتعلق به وبملفه الطبي وعدم إفشاء تلك المعلومات لغير الغراض العلجيه إل فى الحالت التيه :‬
‫6.طلب المعلومات من جهه قضائيه.‬
‫7.وجود إحتمال قوى بحدوث ضرر خطير أو إصابه وخيمه للمريض أو الخرين .‬
‫8.حالت العتداء على الطفال أو الشك فى وجود إعتداء.‬
‫9.حق المجلس القومى للصحه النفسيه فى تكوين لجنه فنيه من الطباء المتخصصين يكون لها الحق فى الطلع على سجلت‬
‫المرضى طبقا للبند رقم 4 من الماده 7 من هذا القانون‬
‫مــادة )93( :‬
‫ل يجوز لغير أفراد الفريق العلجي أو القائمين على السجلت الطبية الطلع على المستندات الخاصة بالمريض إل بإذن كتابي منه.‬
‫.كما ل يجوز استخراج صورة منها إل بإذن من المجلس القليمى للصحة النفسية‬

27. POST TEST
True or False :
3.Legally, consent is only valid when written.
4.Mental capacity is constant in all situations.
5.You can hide information from the patient if these information would harm him.
6.You personal experience is the only key to patient’s best interest.
7.Once the patient agree on a procedure, he have to go through it till the end.
8.You can breach patient’s confidentiality if these information would safe another
person.
9.Confidentiality of psychiatric patients is protected by Egyptian laws

28. REFERENCES
• 100 cases in clinical ethics & law
Carolyn Johnston & Penelope Bradbury
• The Caldicott Guardian
Uk Council of Caldicott Guardian
• Data Protection Act
Information Commissioner
• Mental Capacity Act
UK Legsilation
• Seeking patients' consent: The ethical considerations
General Medical Council
‫بوابة الحكومة المصرية اللكترونية‬
‫موقع المصرى اليوم‬