Transcript Autonomy & Confidentiality (Dr Leena Al

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

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
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
 e-mail
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 the
patient
him/herself
To protect third
parties
Infectious
diseases
Impaired
drivers
Injuries caused
by weapons
and crime
Psychiatric
patients
Abuse
Child abuse
Elder 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