Autonomy & Confidentiality Dr Leena Al-Qasem

Autonomy

A few cases

Case I: You are caring for a patient with cancer. She is refusing to undergo surgery or receive chemotherapy for the treatment of her condition. What would the right action be in this case?

Case II: A patient is being treated by you for a certain condition. He wishes to use alternative forms of treatment for this condition, treatment which you do not believe is effective, due mainly to lack of scientific evidence. Moreover, you believe that the alternative treatment might interfere with the standard treatment and cause the patient’s condition to worsen. How you would handle this case?

Case III: Mr. C. (42 years old) is brought by his wife to the emergency department (ED). He is stuporous, with severe diabetic ketoacidosis and pneumonia. Physicians prescribe insulin and fluids for the ketoacidosis and antibiotics for the pneumonia. Although Mr. C. was generally somnolent and stuporous, he awoke while the intravenous line was being inserted and stated loudly "leave me alone, No needles and no hospital. I'm OK". His wife urged the medical team to disregard the patient's statements saying "he is not himself"

Principles of ethical guidelines:  Autonomy  Beneficence  Nonmaleficence  Social Justice

Autonomy:  Self-determination, independence, and freedom.  physicians should take steps to promote more patient autonomy, as by disclosing information and helping patients deliberate  With regard to health care, autonomy justifies the doctrine on informed consent

Refusal of unwanted medical interventions:  Informed, competent patients may refuse unwanted medical interventions. Such refusals respect patients bodily integrity, patients may not be subjected to invasive interventions without their consent.

Choice among alternatives:  In addition patients may choose among medically feasible alternatives. e.g. choosing whether to have an x-ray or choosing among several drugs for a condition do not implicate the patient's bodily integrity in a manner similar to surgery.

Conflicting choices:  Competent, informed, patients have the right to make choices that conflict with the wishes of family members or the recommendations of their physician.

Autonomy: Treating patients with respect entails several ethical obligations 1.Physicians must respect decisions of autonomous persons. 2.respect for persons with impaired decision making capacity 3.avoiding misrepresentation, maintaining confidentiality, and keeping promises

Autonomy: Who would we consider as autonomous individuals?

Autonomy: Autonomous individuals are: adults have decisional making capacity act intentionally are informed are free from interference and control by others

Autonomy: Why would individuals lose their decisional making capacity?

Autonomy: Age Illness Medication/drugs

Autonomy: Physicians should still treat these patients as persons with individual characteristics, preferences, and values. Decisions should respect their preferences and values as far as they are known.

Autonomy: All patients, whether autonomous or not should be treated with compassion and dignity. Thus respect for persons includes responding to the patient's suffering with caring, empathy, and attention.

Autonomy:  may be justifiably restricted for several reasons: 1. person is incapable of making informed decisions. Respecting autonomy < important than acting in the best interest of the patient.

Autonomy:  may be justifiably restricted for several reasons: 2. constrained by the needs of other individuals or society at large.

Autonomy:  may be justifiably restricted for several reasons: 3. not free to act in ways that violate the autonomy of other people, harm others, or impose unfair claims on society's resources.

Questions about autonomy

Confidentiality

Cases

Case IV:  A 32 years old woman is admitted to the hospital after a serious automobile accident. She is disoriented and confused. The patient's sister requests that the patient's husband not be given any information. The patient has previously told the physician about her hostile divorce proceedings. The husband, however, learns that she is hospitalized and inquires about her condition.

Case IV:  A 61 years old man is diagnosed with metastatic cancer of the prostate. He refuses hormonal therapy and chemotherapy. He instructs his physician not to inform his wife and says he does not intend to tell her himself. The next day, the wife calls to inquire about her husband's health.

Case IV:  A 32 years old male is diagnosed with bacterial meningitis. After the physician explained his diagnosis to him, the risks and benefits, the patient refused to be treated for his illness and insisted on going home.

Case IV:  A woman arrives at the emergency department with serious contusions on the right side of her face and two teeth missing. Her nose appears to be broken. Her husband accompanies her. He explains that she tripped on the carpet and fell down a flight of stairs. She affirms his story. The emergency resident suspects spousal abuse. He does not know the couple, however, and judges by their distress and manner that they appear to be respectable citizens.

Confidentiality:  Patients reveal sensitive information: -emotional problems - alcohol and drug use - sexual activities  The information disclosed may be of interest to parties outside the medical relationship.  The presumption is that physicians maintain confidentiality

Confidentiality:  Traditionally, ethically, and legally guarded  Physicians are obliged to refrain from divulging information  Take reasonable precautions to ensure that such information is not inappropriately divulged

Reasons for confidentiality: Shows respect for patients. Has beneficial consequences Patient Physicians Society

Difficulties with confidentiality 1.Professional indiscretions: Confidentiality has been treated rather carelessly in modern medical care. Speak about patients in public places: hospital elevators and cafeteria. Cell phone conversations

Difficulties with confidentiality 2.Medical records: Records may not be well secured Accessible to many persons  attending physicians  house staff  Students  Consultants  Nurses  social workers  Pharmacists  Secretaries  medical records personnel  insurance company employees  Quality care reviewers

Difficulties with confidentiality 3.Computerized records: enhances statistical information facilitates administrative tasks availability of medical record information to interested third parties many people have access to medical records information can be obtained from any computer station and information on a large number of patients can be accessed at once

Difficulties with confidentiality 4.Other new communication technologies: Fax

Waivers of confidentiality  Patients commonly give physicians permission to disclose information about their condition to others e.g. insurance companies.  Insurers often require clinical information before they reimburse physicians or hospitals.

Waivers of confidentiality  Patients may not appreciate that signing a general releases allows the insurance company to disseminate the information further.  Insurance companies generally place patient’s diagnosis in a computer database that is accessible to other insurance companies or to employers without further permission from the patients.

Overriding confidentiality To protect third parties Infectious diseases Impaired drivers Injuries caused by weapons and crime Psychiatric patients To protect the patient him/herself AbuseChild abuseElder abuse Domestic violence

Overriding confidentiality: 1.The potential harm to identifiable party is serious 2.The likelihood of harm is high 3.There are no less invasive alternative means for warning or protecting those at risk

Overriding confidentiality: 4.Allows the person at risk to take steps to prevent harm 5.Harms to the patient are minimized and acceptable. 6.Disclosure limited to essential information

Questions about confidentiality

Summary

Respect choices of autonomous individuals Autonomy may be justifiably restricted Confidentiality is preciously held principle in medicine May be breached under certain circumstances

Thank you