Profession-patient relationships

PROFESSION-PATIENT RELATIONSHIPS
Sem. Warren Deita
Sem. Slater Wayne Morilla
Sem. Alexie Valiente

I. Rules of Veracity
a. Arguments for Rules of Veracity
b. Conceptual Problems
c. Arguments for Disclosure and
Deception
I. Rules of Privacy
a. Concept of Privacy
b. The justification and limits of Rules of
Privacy
III. Rules of Confidentiality
a. The Nature of medical Confidentiality
b. Foundations of Rules of Confidentiality
IV. Rules of Fidelity
a. The Nature and Place of Fidelity
b. Contracts and Models
c. Conflicts of Fidelity in physicians’ roles
in Nursing and Clinical Research
V. Conclusion
OUTLINE

INTRODUCTION
In the previous chapters we developed four moral principles
applicable to scientific research, medicine, and health care. In
this chapter, we apply these principles to establish rules of
veracity, privacy, confidentiality, and fidelity. We then use
these rules to analyze various relationships between health-
care professionals or researchers on the had and their patients
or subjects on the other. Some of these rules are grounded in a
single principle, while others are grounded in several
principles.

Rules of Veracity
Surprisingly, codes of medical ethics generally ignore
rules of veracity. But, The Principles of Medical Ethics
in America Medical Association in effect from 1957 to
1980 made no mention of an obligation of veracity;
presumably a member physician had unlimited
discretion about what to divulge the patients.

Rules of Veracity
In contrast to the codes, it is commonly agreed that we
have an obligation of veracity, an obligation to tell the
truth and not to lie or to deceive others.
But it does not seem clearly agreed whether Veracity is
an absolute and independent obligation, or a special
application of some higher principle.

Arguments for rules of Veracity
Three arguments for the obligation of veracity are applicable to
relationships between health-care professionals and patients:
1. Obligation of Veracity is part of the respect we owe to others.
2. The obligation of veracity also derives from obligations of fidelity
or keeping promises.
3. Relationships of trust between persons are necessary for fruitful
interaction and cooperation

Conceptual problems
These moral debates about veracity involve conceptual
problems as well as problems of moral justification. Some of
these conceptual problems are definitional, whereas others
concern the scope of term Veracity.
Consider for example, the meaning of LYING. We define lying
as telling another person what one believes to be false in order
to deceive that person.

Conceptual problems
Although the weight of various obligations of every
veracity is difficult to determine outside specific
contexts, some generalizations may be tendered.
Deception that does not involve lying is generally less
difficult to justify than lying, because it does not deeply
threaten the relationship of trust between deceiver and
deceived as does lying.

Conceptual problems
By contrast to the obligation not to lie and the
obligation not to deceive, the obligation to disclose
usually depends on special relationships between the
parties involved.

Conceptual Problems
Many subtleties about the nature of veracity are present in
discussion of these obligations. As with confirmed consent,
courts of law have typically assimilated obligations of
veracity to obligation of disclosure. Veracity refers to
comprehensiveness, accuracy, and objectivity with which
information is handled, as well as the manner in which
understanding is fostered in the relationship.
“Consent may not be a factor.”

Arguments for limited
disclosure and deception
We considered some conditions that must be satisfied in order
to justify deception and incomplete disclosure in research.
Those conditions were so narrowly drawn that most biomedical
and social-science research involving intentional deception
would be unjustified. Nevertheless, we held that some low-risk
research involving minor deception or incomplete disclosure
could be justified if the undisclosed information would have
invalidated the research had been disclosed.

Issues of veracity, limited disclosure, and deception are
not limited to these contexts of consent and refusal. For
example, provision of information regarding diagnosis
and prognosis may have no role in process of consent
or refusal.

(Example case)
In case 5, a 54-year-old male patient consented to surgery for probable
malignant cell transformation in his thyroid glans. After the surgery, Mr. X was
told that the diagnosis had been confirmed and that the tumor had been
successfully removed, but he was not informed that there was a likelihood of lung
metastases and death within a few months. Although his wife, son, and daughter-
in-law were all informed by the physician, they and the physician agreed to
conceal the diagnosis and prognosis from Mr. X. He was told only that he needed
“preventive” treatment, and he consented to irradiation and chemotherapy. He
was not informed of the probable cause of his subsequent shortness of breath and
back pain. And he was not given a chance to discuss his impending death,
because everyone pretended that he would soon recover. He died three months
later.

Sometimes it is unclear whether the physicians believe
that the obligation of disclosure is directed at the
patient or at the family. The 1979 study reveals a
significant ambiguity about the role of the patient’s
wishes and of the family’s wishes in withholding
information about cancer.

According to the physicians surveyed, the four factors “most frequently believed to
be of special importance” in deciding whether to tell the cancer patient:
Option 1
52% - Patient’s expressed wish to be told
21% - Emotional stability
11% - Age
10% - Intelligence
Option 2
56% - Decision to tell the patient as
of age
51% - relative’s whishes regarding
disclosure to the patient
47% - Emotional Stability
44% - Intelligence

Rules of Privacy
Privacy and confidentiality are often discussed
together, as in federal regulations that require
protection of privacy and confidentiality in research
involving human subjects and in American Nursing
Association Code of Ethics which requires nurses to
safeguard “the clients right to privacy by judiciously
protecting information of a confidential nature.”

Rules of Privacy
The U.S. Supreme Court early in 1920s employed an
expansive “liberty” interest to protect family decision-
making about various issues, including child rearing
and education. The Court later switch to the term
Privacy and expanded the individual’s and family’s
protected interests in life, child rearing and other areas
of personal choice.

Concept of Privacy
Privacy maybe defined as “a state or condition of limited access to a person” so a
person has a privacy if others do not have or do not use access to him or her.
Privacy focuses on the agent’s control or rightful control over access to himself or
herself.
These definitions confuse privacy, which is a state or condition, with either control
over privacy or the right to privacy, which involves the agent’s rightful control
over access.

Concept of Privacy
A person’s privacy (or loss of privacy) should not be confused
with the person’s sense of privacy (or sense of loss of privacy).
A loss of privacy may depend not only on the kind or amount
of access but also on who has access through what means to
which aspect of the person.

Concept of Privacy
As Charles Fried notes:
We may not mind that a person knows a general fact about us,
and yet feel our privacy invaded if he knows the details.

The Justification and limits of
Rules of Privacy
Several types of justification and the right to privacy has
been prominent.
1. One approach reduces the right to privacy to a cluster of
the other rights. Judith Thompson contends that the right
to privacy is ‘derivative’ in this sense.

Rules of Privacy
2. Another and more promising approach emphasizes the
instrumental value of privacy and the right to privacy by
identifying various ends that are served by rules of privacy.
Charles Fried said:
“It is my thesis that privacy is just not one possible means
among others to ensure some other value but that it is necessarily
related to ends and relations of the most fundamental sort:
respect, love, and trust.”

Rules of Privacy
One possible objection to our use of respect for autonomy as
the justificatory basis of rule of privacy is the following.
Suppose that a patient in a hospital leaves a sealed note for a
night nurse. A physician who suspects a conspiracy between
the two not to follow a prescribed regimen opens and reads
the note while the patient is asleep.

Rules of Privacy
So if there is no disrespect for autonomy, then it would seem that the
right to privacy is not based on respect for autonomy.
Respect for patient’s autonomy requires that no one reads without being
autonomously authorized to do so by the patient. Reading the note
without consent is as much a violation of autonomy as proceeding to
surgery without consent. In this way, any such violation of a right of
privacy is a violation of a right of autonomy.

Rules of Privacy
Finally, to affirm the right to privacy, as we have, does not
rule out moral criticism of various ways people exercise this
right. For instance, a person may choose to lose privacy in a
degrading or cheapening manner or to maintain privacy for
foolish reasons. This criticisms maybe appropriate but still not
sufficient rounds for paternalistic or moralistic intervention.

Rules of Confidentiality
Ex:
Our physician may not grant an insurance
company or a prospective employer access to that
information without our authorization.

When others gain access to such protected information
without our consent, may sometimes describe their
access as an infringement of confidentiality and at
other times as an infringement of privacy.

Confidentiality – refers to personal information shared
with an physician, therapist or other individual that
generally cannot be divulged to third parties without
the express consent of the patients. On the other hand,
Privacy – refers to the freedom from intrusion into
one’s personal matters and personal information.

The difference between infringement of confidentiality and
infringement of privacy
An infringement X’s confidentiality occurs only if the person to whom
X disclosed the information in confidence fails to protect that
information or deliberately discloses it to someone without X’s
consent.
A person whose sneak into a hospital record room or breaks into a
hospital computer data bank, despite appropriate protections would be
accused of a violation of privacy rather than a violation of
confidentiality.

Traditional rules and Contemporary
practices in Health Care
Western codes of medical ethics, the requirements of
confidentiality appears as early as the Hippocratic Oath
The vow contains “ What I may see or hear in the course of
the treatment or even outside of the treatment in regard to
the life of men which on no account one must spread abroad,
I will keep to myself holding such things shameful to be
spoken about.”

In 1957, the code of Ethics of the American Medical
Association adopted this rule:
“A physician may not reveal the confidences intrusted to him
in the course of medical attendance, or the deficiencies he
may observe in the character of patients, unless he is
required to do so by law or unless it becomes necessary in
order to protect the welfare of the individual or the
community.”

In 1980, the AMA revised this rule to hold that a
physician “Shall safeguard patients confidences within
the constraints of the law.”
International Code of Medical Ethics (1949) “A doctor
shall preserve absolute secrecy on all he knows about
his patients because of the confidence entrusted to
him.”

A Patient’s Bill of Rights (1973)
The American Hospital Association, one rule is “The patients
has the right to every consideration of privacy concerning
his own medical care program.”
“The patients has the right to expect that all communication
and records pertaining to his care should be treated as
confidential.”

The nature of medical confidentiality
Confidentiality is present when one person discloses
information to another, whether through words or an
examination, and the person to whom the information is
disclosed does not divulge that information without the
other person’s permission.
A rule of confidentiality prohibits some disclosures of some
information gained in certain relationships to third parties
without consent of the original source of the information.

Foundations of rules of confidentiality
A rule of confidentiality may be justified either by the principles it
expresses or by the consequences it produces. It enables
physicians to meet the needs of patients to have information both
transmitted and protected. If the patients could not trust
physicians not to reveal some information to third parties, they
would be reluctant to disclose full and forthright information in
the first place. Without that information, physicians would not be
able to make diagnosis and prognoses or to recommend the best
course of treatment.

The Nature and Place of Fidelity
Paul Ramsey maintains that the fundamental ethical
question in research, medicine, and health care is, “What is
the meaning of the faithfulness of one human being to
another?” Ramsey interprets faithfulness along theological
lines as covenant fidelity, but is often expressed in
philosophy in terms of fidelity or promise keeping and in
law in terms of contracts, trust, or fiduciary relations.

Rules of fidelity are rooted in respect for autonomy as
well as utility. These principles provide strong warrant
for an individual’s obligation to keep promises as well
as for an institution of promising.

In establishing a relationship with a patient and
physician makes an implicit or explicit promise to seek
the patient’s welfare. This promise appears in the
physician’s pledge or oath upon entry into the
profession or in the profession’s code of ethics.

The content of specific obligations of fidelity depends on the promise that
were made, the expectations that were legitimately engendered, the nature
of the special relationships, and like. For example, it might be argued that
although the pregnant woman has a right to terminate her pregnancy by
abortion, her decision not to abort and to carry the pregnancy to term
engenders certain moral (not necessarily legal) obligations of
nonmaleficence and beneficence to the fetus. In such cases, by exercising
their autonomy in certain ways, people change the structure of obligations
and rights and in so doing limit their future autonomy from a moral (even
if not from a legal) standpoint.

Contracts and models
Contract refers to voluntary agreements between parties that create or
alter legal obligations.
Contracts play a large role in human interactions, and their
importance is indicated by legal sanctions.
Contracts became progressively significant in law and ethics as
contractual relations supplanted status and relations in the modern era,
especially when contracts became central in capitalistic markets.

Contracts and models
CASE 23, THE CASE OF BABY M
A controversy about the legal enforcement of a contract for
surrogate motherhood when the surrogate mother changes her mind
and intents to keep the baby.
Critics contend that such contracts should be voided because they are
immoral and resemble unenforceable contracts for prostitution and the
sale of children

Conclusion
In this chapter, we have applied the four principles of
respect for autonomy, nonmaleficence, beneficence,
and justice to relationships in research and health care.
We have concentrated on rules derived from these
principles – the rules of veracity, fidelity,
confidentiality, and privacy.

Conclusion
In each instance, we have explored the basis, meaning,
limits, and stringency of these rules in the context of
professional and patient or subject relationships. These
rules, like the principles on which they depend, are
prima facie binding, and our analysis has indicated
some conditions under which we can be overridden.

Conclusion
Morality include more than these principles and rules.
When conflicts occur between prima facie obligations,
we often recognize that the character traits of a person
who must make a judgment are no less important than
obligations derived from principles and rules.

Conclusion
Several times in this chapter we have appealed to the
importance of virtues such as truthfulness and
trustworthiness. Any adequate ethical theory must also
attend to these virtues, to integrity, which is often
expressed in terms of conscience, and moral ideals. We
turn to these topics in final chapter.

Profession-patient relationships

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