Principles of Confidentiality and Truthfulness, Ch. 5 Health Care Ethics

Truthfulness Truthfulness can be specified by two hypothetical commands: If you communicate, do not lie (refusing to communicate is not lying) You must communicate with those who have a right to communication (not everyone has a right to know what you know, or all you know)

Lying What is lying? The book cites a traditional understanding of lying, calling it “speech against the mind” –p110 (112 4th ed) That definition, however, leads us to classify assertions in play acting, humor, games, etc., as lies, which seems wrong. Instead, the book considers those speech acts against the mind, uttering falsehoods.

Lying Lies will then be falsehoods uttered in circumstances where others have a reasonable expectation of the truth Why not, simply, “where others have a right to the truth”? A lie surely does occur when we utter falsehoods to those with a right to the truth, right? Imagine someone asking … What color is your car? What time is it? Are those shoes Doc Martens?

‘Reasonable Expectation’ The book provides 3 ways to assess “reasonable expectation”: The place of communication The roles of the communicators The nature of the truth involved All 3 are connected with the obligation of confidentiality and the right of privacy

‘Reasonable Expectation’ On p 112 (114 4th ed) read about special contexts that affect reasonable expectation such as business, advertising, law (self-incrimination), and between volunteering information and being asked

Right to the Truth In medical contexts, the book offers 3 categories where we have a right to the truth from others, or conversely, an obligation to provide it to them: The information in informed consent The information paid for by patients The information needed for important nonmedical decisions

Right to the Truth Like what important nonmedical decisions? Like the right of patients to know that they are dying, which is important for settling financial affairs personal affairs making peace with God settling disputes with family, friends, enemies simply saying goodbye

Right to the Truth The Placebo Problem: Placebos involve medical deception. Can they ever be used outside of research? (if you consent to participate in a research study knowing you may not be treated with active pharmacological agents, everyone agrees the deception is trivial) P 114 (116 4th ed) the book discusses all the ways placebos can be used to good effect.

Right to the Truth The Placebo Problem… P 115 (117:4th ed) the book offers this example of a permissible non-research use of a placebo: If the physician says “I am going to prescribe something that often helps in these cases and has no bad side effects,” it is hard to see how he is deceiving the patient. Certainly he is not lying. In such a presentation, the patient knows what she or he needs to know in order to give informed consent. No untruth is spoken, and No information to which the patient has a right is suppressed.” Does this sound right to you?!

Confidentiality “Confidentiality is concerned with keeping secrets.” –p115 (117 4th ed) “A secret is knowledge that a person has a right or obligation to conceal.” –p115 (117 4th ed) Hello! … is that right? There are: Natural secrets Promised secrets Professional secrets

Confidentiality Natural secrets: Secrets whose revelation would cause harm by nature: Letting others know what you know about someone’s binger someone’s social disease someone’s infidelity someone’s foot odor problem someone’s bad grade

Confidentiality Promised secrets: “… knowledge we have promised to conceal.” -p116 (118 4th ed) “The special evil of revealing promised secrets arises from the harmful effects of breaking promises.” –p116 (118 4th ed) -depending on what is meant by “special,” this may be false for some Kantians, deontologists generally (again with consequences … sheesh!)

Confidentiality Professional secrets: “…knowledge that, if revealed, will harm not only the professional’s client, but will do serious harm to the profession and to the society that depends on the profession for important services.”

Confidentiality Professional secrets (cont.): The book lists these exceptions to the professional duty of confidentiality between health care provider (mainly physician, sometimes nurse) and patient: Exceptions: Medical consultation State law (gun and knife wounds need reporting) Court decisions (similar logic to law, different standard) Unusual relationships (if doctor’s role is to determine health status for company, army, etc.) Proportionality (good of revelation outweighs bad of divulging a confidence) [read p120-1 block (123 4th ed]

Confidentiality Professional secrets (cont.): Family (law has changed to exclude immediate family from doctor-patient confidence … family is not considered the patient as it once was) Children and adolescents [read p117 (119) and p123 (125 4th ed) blocks] Is there are conflict of interest that goes without discussion here? Coincidence of public good with financial health of hospitals and clinics? What if activism, ads better controlled epidemic? Would such be considered medical treatment? Media publicity for celebrities and politicians Third party payers (insurance companies need to know medical information) Public good (AIDS and HIV information) HIV-positive provider (must disclose information to patient?)