Doctor-Patient Relationship: Veracity, Privacy, and Confidentiality PDF

DOCTOR-PATIENT RELATIONSHIP: Veracity, Privacy and Confidentiality Prof. Bernat Tort Centro de Humanidades Biomédicas Universidad Central del Caribe “Veracity does not consist in saying, but in the intention of communicating the truth.” Samuel Taylor Coleridge Introduction:  Th...

DOCTOR-PATIENT RELATIONSHIP: Veracity, Privacy and Confidentiality Prof. Bernat Tort Centro de Humanidades Biomédicas Universidad Central del Caribe “Veracity does not consist in saying, but in the intention of communicating the truth.” Samuel Taylor Coleridge Introduction:  The concepts, rules and obligations of veracity, privacy and confidentiality have become a very important part of medical practice and, as well as of the doctor-patient relationship. Veracity  The norm, virtue or obligation of telling the truth when asked for it. Social Veracity  Socially, there is no real expectation of absolute or general veracity. ⚫ Ex: When asked on the street “How are you?”, people don’t expect a truthful report on your life matters but a simple “Fine, and you?” or “You know, with ups and downs”, etc.  But there is an expectation of specific veracity in relation to questions like “What time is it?”, etc. Also within intimate, familiar and work related relations. Medical Veracity  It is the norm or obligation that compels health care professionals (or researchers) to tell the truth and nothing but the truth to the patient, with regard to their health and their medical records.  “Veracity in the health care setting refers to comprehensive, accurate, and objective transmission of information, as well as to the way the professional fosters the patient’s or subject’s understanding.” [Beauchamp & Childress, 284] Medical Veracity: Historical perspective  The expectation and application of the norms of medical veracity are curiously recent in the development of medical ethics.  There is no mention of this rule rule in the Hippocratic Oath.  It isn’t until 1980 that it appears vaguely in The Principles of Medical Ethics of the American Medical Association, where it simply states: “treat your patients and colleagues honestly”. Medical Veracity: Historical perspective (cont.)  The interest in medical veracity is contemporary with the development of Bioethics and, in particular, with the development of the Principle of Autonomy. Veracity and Paternalism  Historically, the paternalistic attitude of the medical class which justified their non- adherence to the obligation of veracity was based in three presuppositions: 1. The uncertainty of information (statistical knowledge cannot be applied to a particular case) (What does The Truth mean in this case?) 2. The difficulty of explaining and comprehending technical and medical issues (“he won’t understand”) 3. Beneficence (“it is better if she doesn’t know”) Objections to paternalism 1. Truth should not be confused with Veracity (truthfulness). It is not about establishing absolute certainty in a diagnosis, but about a truthful exchange between people. [Higgs, 434] 2. Appealing to the “mysticism” of medical ideas as an excuse for not dealing with giving a non- technical explanation of a diagnosis is a sign of mediocrity and laziness more than insuperable difficulties. Every professional, specially a doctor, must be able to explain what she does to a non- professional. [Higgs, 434] Objections to paternalism: the white lie and non- intended consequences  Decisions with transcendental consequences should not be made for others. We never know what non- intended consequences our omissions may have. [Higgs, 434-435]  Ex: Not informing truthfully or omitting information about a diagnosis of terminal cancer may limit the possibilities of a patient, a single mother, for example, of providing for the care of her children, their custody, or saying goodbye adequately, looking for the best palliative care, looking for a second opinion about her condition, etc. Socrates and philosophical death  “The unexamined life is not worth living.” –Socrates ⚫ Knowledge of the proximity of death can open up a process of self-reflection and healing (emotional and spiritual).  Ex: The confession and/or extreme unction for a catholic. ⚫ Getting their affairs in order, emotional, familiar, etc. ⚫ Preparing to die:  Ex: “Death Poems”: a Japanese tradition (¿What would you do if you were told you had only ten days to live? ¿Would you come tomorrow to the University?) Veracity, paternalism and autonomy  The consequences of adopting a radical paternalism that discards the obligation to veracity, would force a patient to choose between his health and his autonomy.  The autonomous decision and, therefore, consent, have veracity as a necessary condition. Veracity: the clinical encounter  There are three different but related aspects in considering what veracity consists of in medical practice and, in particular, in the doctor-patient relationship. 1. Diagnostic veracity 2. Informative veracity 3. Communicative veracity 1. Diagnostic Veracity  Make sure of the accuracy of your diagnosis and conclusions, using reliable and up to date medical data (repeat a test if there are doubts about a result). [Frontera, 5]  If in doubt, investigate about possible courses of action, standard and experimental procedures before making a prognosis and recommending a treatment.  Only with reliable information can you inform adequately and facilitate the decision making process. 2. Informative Veracity  Informing, explaining and guaranteeing the comprehension of the patient, through a truthful exposition of the situation.  Make sure that the patient understands through an exercise of Q &A.  Communicate the information slowly, and stop and rephrase whenever you notice a gesture of incomprehension (remember that a misunderstood truth is no truth).  Only through information can we maximize the right of a patient to lead her life autonomously and according to her values and goals. 3. Communicative Veracity  “[I]n health care ethics […] how a truth is told may be as important as what it conveyed.” [Higgs, 437]  Be tactful at the time of communicating bad news. Don’t blurt out the truth in a cruel and crude manner (what is known as “truth dumping”). Remember that what is mere information for you, is vital (“pun intended”) information for your patient.  Take your time. Sometimes it may be better to give out information in small doses, to promote better “digestion”.  The place you choose to communicate bad news is also important. Communicative Veracity (cont.)  Contemplate, meditate and anticipate possible reactions and doubts and be prepared to give out answers.  Do not improvise! If you don’t know something, say it.  Consider cultural, religious and psychological factors. ⚫ Example: Get to know the psychological stages in the management of bad news. Five Stages of Grief (Kübler-Ross Model) 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance 3 Stages of Grief (another approach) 1. Numbness 2. Disorganization 3. Reorganization Veracity, Paternalism: Hope vs. Self-Deceit  There is a fine line between tact and sensibility while communicating bad news and paternalism, and it could promote self- deceit in the patient.  Do not lead the patient into having false expectations. Be truthful without being cruel and without crushing his hope. ⚫ Emphasize on the advances and progress of a treatment (for example, physical rehabilitation) more than its weaknesses. Cultural Relativism and Veracity  Cultural aspects may sometimes hinder the process of truthful communication of information for medical treatment. ⚫ Ex: The Navajo believe that “thought and language have the power to shape reality and to control events”. [Beauchamp & Childress,62]  In these cases there must be provisions, for example, an ombudsperson or representative of the community who knows the due process for being respectful of the beliefs and the culture in question. Cultural Relativism and Veracity (cont.)  It could be argued that the cultures that believe that “saying something makes it happen” are simply wrong in their beliefs and therefore, the obligation of veracity should not accept this exception. This argument doesn’t take into account that the basis of the rule of veracity lies not in the principle of Non- maleficence or Beneficence, but in the principle of Respect for Autonomy. Possible Exceptions to the Rule of Veracity 1. Clinical trials with placebos. ◆ It is not really an exception since the patient has already agreed to be kept in the dark. 2. Manipulating the truth for third parties who pay the medical bills. ◆ Manipulating the truth in medical records to guarantee better coverage by health insurance. 3. Deceit of third parties to protect the patient ◆ Omission or deceit in a genetic clinic regarding paternity to protect the mother when the father is not a patient of the clinic, be it to protect the family or to protect the mother in a chauvinistic society where her life could be in danger. 4. When the patient autonomously decides not to be informed. ◆ In this case the principle of Autonomy surpasses the rule of veracity. Veracity and Labor Conflicts  Problems with addiction and substance abuse by a colleague.  Knowledge of negligent practices by a medical colleague.  Acceptance or concealment of your own mistakes in medical practice. “Those who would give up essential liberty to purchase a little temporary safety, deserve neither liberty nor safety.” Benjamin Franklin Privacy 1. The right of an individual to control access to his own person, information and life. This includes the right to relinquish this right. 2. The obligation to respect and preserve this right in other individuals. Types of Privacy 1. Information privacy 2. Physical privacy Body or personal space 3. Decisional privacy 4. Property privacy Information, genetic material, extracted organs, tissues, etc. 5. Relational or associational privacy It includes family or close persons Three problematic cases  HIV/AIDS ⚫ Tests and sampling (¿compulsory or voluntary?)  Tuberculosis ⚫ Treatment and detection (¿compulsory or voluntary?)  Genetic information ⚫ Access Privacy and autonomy  The right to privacy is grounded on the principle of Respect of Autonomy.  It could be argued that the reasoning behind the right to privacy is grounded on the principle of Justice. Genetic information and privacy  The right to privacy in relation to genetic information, its use and management, has generated great debates.  There are evident conflicts between free access to genetic information and the principle of Justice. Some of them are: ⚫ Medical insurance and genetic information ⚫ Labor discrimination ⚫ Social discrimination ⚫ Genetic determinism ⚫ Discrimination against asymptomatic patients Confidentiality  “Confidentiality is present when one person discloses information to another, whether through words or an examination, and the person to whom the information is disclosed pledges not to divulge that information to a third party without the confider’s permission.” [Beauchamp & Childress, 305-306]  “By definition, confidential information is both private and voluntarily imparted in confidence and trust.” [Beauchamp & Childress, 306] Justification of the rule of confidentiality  There are three arguments that justify the rule of confidentiality: 1. Consequence-based arguments 2. Rights-based autonomy and privacy arguments 3. Fidelity-based arguments 1. Consequence-based arguments  Those that argue that the basis of following the rules of confidentiality is the sum of social benefits they bring. ⚫ Ex: The presumption of confidentiality promotes veracity in patients which enables better medical care and therefore augments general social benefits.  They can also be used against the rule of confidentiality. 2. Rights-based autonomy and privacy arguments  We have seen the negative consequences that lack of privacy and indiscriminate access to information brings about, and precisely because of these reasons the necessity of following the rules of confidentiality is justified. 3. Fidelity-based arguments  The fidelity that a doctor owes to her patient and that serves as foundation for the development of the trust that a patient has for her doctor, her opinions and advise would be negatively affected if an implicit (and explicit) agreement of confidentiality and discretion in the management of information were not presumed. Types of confidentiality agreements  Explicit confidentiality  Implicit confidentiality Difference between the right to privacy and the right to confidentiality  Only an institution that has received confidential information and mismanages it or unlawfully distributes it can be accused of infringing the patient’s right to confidentiality.  On the contrary, if access to the patient’s information is reached through illegal means and without the consent of the institution, then the infringement is on the right to privacy. Unrealistic expectations concerning confidentiality  Conceiving confidentiality as an exclusive relation between doctor and patient in contemporary healthcare contexts is simply unrealistic.  Who has (an who should ) have access to the patient’s medical information? Some exceptions to the rule of confidentiality [Gillon, 425-426] 1. When the patient authorizes the use of information 2. In cases when the patient’s authorization may be legitimately inferred (i.e. emergencies) 3. When it is in the best interest of the patient (i.e. cases of suspicion of abuse) 4. For medical purposes: teaching , or research (in such cases the identity of the patient must be protected) 5. In order to avoid harm to third parties Privacy, confidentiality and veracity: the management of genetic information  To whom does genetic information belong?  Possible conflicts between veracity and confidentiality: ⚫ Ex: when a physician has more than one genetically related patients.  Possible conflicts between privacy and confidentiality, and the principle of justice and beneficence: ⚫ Do insurance companies have a legitimate claim to the genetic information of their clients? ⚫ Do people with genetic hereditary disabling conditions have the right to privacy when choosing a partner for reproduction, or when they have public health insurance? References  Beauchamp, Tom L. and James F. Childress. (2001). Principles of Biomedical Ethics. New York: Oxford University Press.  Frontera, Ernesto A. (2003). “La relación médico-paciente: concepto medular de la bioética clínica.” Power Point Presentation for “el Centro de Humanidades Médicas”. Photocopy.  Gillon, Raanan (2001). “Confidentiality” in Helga Khuse and Peter Singer (2001)(eds.). A Companion to Bioethics. Malden: Blackwell. Pp.425-431.  Higgs, Roger (2001). “Truth-Telling” in Helga Khuse & Peter Singer (2001)(eds.). A Companion to Bioethics. Malden: Blackwell. Pp.432-440.  Hope, Tony (2004). Medical Ethics: A Very Short Introduction. Oxford: Oxford university Press.  Jansen, Albert R., Mark Siegler and William J. Winslade (2002). Clinical Ethics: A Practical Guide to Ethical Decisions in Medicine. New York: McGraw-Hill.