1. Confidentiality Toby L. Schonfeld, Ph.D. Department of Preventive and Societal Medicine tschonfeld@unmc.edu

3. What’s at stake

4. What confidentiality is How it is promoted by professions Why confidentiality is important Justified instances of disclosure Types of sanctions How do we navigate difficult cases?

5. Confidentiality is... “A socially publicizable and enforceable pledge to keep secret or hold in confidence any information about the client which is gained by the professional during the normal course of client- professional interactions.” –Rem B. Edwards, “Confidentiality and the Professions,” Bioethics (.....)

6. Specific Statements of Professional Promotion Nuclear Medicine Code of Ethics Principle III: “The Nuclear Medicine Technologist will maintain strict patient confidentiality in accordance with state and federal regulations.”

7. Specific Statements of Professional Promotion American Dietetic Association Code of Ethics Principle IV: “The dietetic practitioner maintains confidentiality of information. “

8. American Society of Radiologic Technologists “The radiologic technologist respects confidences entrusted in the course of professional practice, respects the patient's right to privacy and reveals confidential information only as required by law or to protect the welfare of the individual or the community. “

9. Why keep patient information confidential? Fundamental human values Rules of Confidentiality Professional behavior

10. Why keep patient information confidential? (1) Privacy Information about ourselves we do not want disclosed to others –General: Physical facts Mental facts Behavioral facts –Specific Risks associated with the violation of privacy

11. Why keep patient information confidential? (2) Social Status Confidentiality affirms and protects the social status of the client –Marginalized groups –Stigmatizing conditions –Community members

12. Why keep patient information confidential? (3) Economic Advantage Confidentiality is economically advantageous to the patient –Economic stigmatization

13. Why keep patient information confidential? (4) Open Communication Confidentiality promotes open communication between provider-patient –Encourages patients to disclose intimate details –Violations of confidentiality cause patients to withhold essential information

14. Why keep patient information confidential? (5) Seeking help Confidentiality encourages patients to seek professional help. –Open communication first requires the patient to come to the office –Studies show that seeking help is a cost/benefit analysis: professional service gains vs. confidentiality losses

15. Why keep patient information confidential? (6) Trust Trust: confidence that we can depend on the competence, integrity, support, care, and concern of another –ABIM Charter: commitment to professional competence –Violation of trust results in contempt, deep alienation, suspicion

16. Why keep patient information confidential? (7) Promotes autonomy Autonomy: capacity for making decisions HIPAA: information is in the control of the patient Principle of patient autonomy: Charter

17. Disclosure “Need to know” information Sometimes we have other values that will conflict with our value of confidentiality

18. Disclosure Legitimate breaches of confidentiality must consider the following points: –There is no less costly way of promoting the competing values –The conflicting value will be significantly advanced by violating confidentiality –Competing value is more important than the 7 confidentiality values

19. Specifics of disclosure When are breaches acceptable or required? –Violent wound reports –Suspicion of abuse or neglect –Danger to self or others –Communicable diseases

20. Sanctions Moral sanction: conscience Social sanction: public opinion Legal sanction: positive law and means of enforcement

21. Now back to the case...

22. Options Recommend that Al inform his partner Facilitation of disclosure Risk reduction Explore Al’s values Call the health department Set time limit for Al’s disclosure to partner Dismiss Al from your practice Disclose risk to Al’s partner

23. Competing values Privacy rights of Al vs. autonomy rights of partner Autonomy rights of partner vs. risk to physician-patient relationship Responsibility to patient vs. responsibility to public

24. Criteria for breaching confidentiality Is the burden met here? –Alternatives to disclosure –Which “conflicting values” will be advanced? –Are these values more important than the 7 fundamental values?