1. health and fitness

Clinical Case Reports and Reviews
Case Study
Preserve patient’s confidentiality in primary care
Basem Abbas Al Ubaidi*
Consultant Family Physician, North Muharaq Health Centre, Kingdom of Bahrain
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
Case study
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].
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.
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].
Clin Case Rep Rev, 2015
doi: 10.15761/CCRR.1000116
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].
Correspondence to: Basem Abbas Al Ubaidi, ABFM, MHPEd, Consultant
Family Physician, North Muharaq Health Centre, Kingdom of Bahrain, E-mail:
bahmed1@health.gov.bh
Received: March 10, 2015; Accepted: April 01, 2015; Published: April 05, 2015
Volume 1(3): 42-44
Al Ubaidi BA (2015) Preserve patient’s confidentiality in primary care
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
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
Clin Case Rep Rev, 2015
doi: 10.15761/CCRR.1000116
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.
curricula.
To formulated new practical goals for family medicine ethics
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?
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.
7. BMA (1999) Confidentiality and disclosure of health information.
8. General Medical Council (2009) Confidentiality: protecting and providing information
2009.
9. Slowther A (2010) Confidentiality in primary care: ethical and legal considerations.
InnovAiT3: 753–759.
10. General Medical Council. Confidentiality (2009a) London: GMC. Accessed via
www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp. [last date accessed
28.10.2014].
11. O’Neill O (2002) Licence to decieve. Reith lectures.
Volume 1(3): 42-44
Al Ubaidi BA (2015) Preserve patient’s confidentiality in primary care
12. 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.
14. 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]
13. (1984) Gillickv West Norfolk and Wisbech Area Health Authority. All Engl Law
Rep1985: 533-59. [Crossref]
15. http://ministryofethics.co.uk/index.php?p=6&q=7.
16. http://www.legalaffairs.gov.bh/LegislationSearchDetails.aspx?id=4069.
Copyright: ©2015 Al Ubaidi BA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Clin Case Rep Rev, 2015
doi: 10.15761/CCRR.1000116
Volume 1(3): 42-44