We've talked about times when it's
necessary to disclose information
learned in confidence for patient care or
for billing or for other clinical reasons.
There are also going to be times when it may be necessary
to breach confidentiality for the interest of other people.
And we'll talk a
little bit about that.
So the default physician should always be to protect the patient's
privacy, but there are going to be exceptions to the rule.
So, one is going to be by law
or statute or court order.
There is a requirement to release
that private information.
So, often for infectious diseases, the health department
will require reporting of that infectious disease
so that there can be contact tracing to anybody that might
have been exposed to the patient with the infectious disease.
There may be requirements when it's issues of
harm to a child or to an adult in the community
where there are issues of abuse or
neglect required by law to report that.
There, you're going to be able to breach
the confidentiality of the patient.
So it could either be for the individual patient's care
that you're needing to do it or the needs of others.
When might it be necessary
for the individual patient?
Well, let's say it's an emergency situation and you need more
information in order to assist in making treatment decisions.
There, you might need to, you know, one of my
patients is in an emergency room in another state
and they're contacting me to figure out, you know,
what medications they're on, what diagnoses they have
that's going to have implications for how
they manage the patient in that other site.
There, the breach is for
the patient's benefit.
I can't get a signed, you know, form from the patient agreeing to this
disclosure but it's in their interest that I disclose this information.
There may be ancillary staff needing
access for the process of care.
We've talked about how big the healthcare team can be, all the
people that may be involved in providing care to the patient.
There, that might be necessary especially if it has implications for that
staff member if they might be exposed to infectious disease, for instance.
Providing information to a surrogate decision-maker
to make clinical decisions on behalf of the patient.
So we talked a little bit about
patients who have limited capacity
while the default is generally going to be once you've
found an authorized decision-maker for the patient,
there needs to be disclosure to that surrogate if it's information that
will be relevant to making treatment decisions on behalf of the patient.
There can be tricky situations of, you know, a judgment call on
the part of the clinician of how relevant is the information
to making this current decision, you know, so a past history of HIV, the
patient has an established diagnosis of human immunodeficiency virus syndrome
and the question is, you know, is that relevant to managing their heart
attack now and the surrogate is needed to make decisions for their care.
You have to make a judgment as to "Is this
relevant to the informed consent process?"
There may be times when there are breaches in the
needs of others and that's also going to happen,
you know, in the public health arena so I've
talked a fair amount about contagious diseases.
So, when it's necessary for quarantining,
when it's necessary to track or even prevent
the transmission of sexually transmitted diseases or other
infectious diseases, whether it's for cancer registry.
So, knowing, you know, what cancer the
patient had, how they were treated,
what their outcomes of treatment were, a lot of municipalities
will have tumor registries where this data is collected
and then on a population level you can
know how we're managing cancer treatments.
So, not a sake with patient permission
but in the needs of the public interest.
When there are concerns about the patient
posing a risk to the general public.
So it's a patient that likes to drive cars, but
you're concerned about their safety on the road
whether they have a disease process like a seizure
disorder, if they have visual impairment,
or they have, you know, diabetes and
might be prone to hypoglycemia.
You're worried that they might pose a
risk to others if they're on the road.
Again, a judgment call is to whether or not you
would need to report that in some jurisdictions,
either give discretion to the clinician to make that judgment call or
may actually require the reporting to the department of motor vehicles.
And then lastly, there might be times
when it's, you know, really serious.
A bioterrorism attack, a mass casualty threat, you
know, the patient has shared with you that they are,
you know, going to cause
serious harm to a community.
There again you can break confidentiality
in the interest of the public.
The biggest category where this generally comes up for
clinicians is when it's an identifiable 3rd party.
It's not the public at large, but it's an
actual person that you know their identity
and you have to make a judgment of is it sufficiently important to break confidentiality
of my patient in order to protect this individual, this other 3rd party.
So, again, we're always thinking with privacy about the liberty rights of
the patient, but can they be forsaken in the interest of this other person?
The famous case where this came up is
something called the Therasoft decision.
So this was a young man who is dating a woman.
They were both in college.
They broke up. He was
distraught about the break-up.
He sought the assistance of a mental health counselor at the university, described
that he was so upset by this that he was going to kill his ex-girlfriend.
The counselor tried to detain him, tried to call security, and you
know, make sure that he did not get access to this ex-girlfriend.
They detained him for a period of time, but
he didn't seem to be a threat anymore.
They released him out into the community.
He then went and killed his ex-girlfriend.
So, her parents sued the university, saying that they should
have done more to protect her and warn her of this threat.
No one directly warned her that he had
made these threats about killing her.
So this was the opinion in the Therasoft
decision, this court case that happened.
When the therapist determines or pursuant
to the standards of his profession
should determine that this patient presents
a serious danger of violence to another.
He incurs an obligation to use reasonable care to
protect the intended victim against such danger.
The discharge of this duty may require the
therapist to take on one or more various steps.
Thus, it may call for him to warn the intended victim, to notify the police,
or to take whatever steps are reasonably necessary under the circumstances.
So this duty to warn when there is a threat to the well-being
of a 3rd party became known as the Therasoft rule.
And this is where we get to when it's permissible for
clinicians to breach privacy or confidentiality.
And there are going to be certain requirements
that had to be fulfilled in order to,
you know, this important principle of
protecting privacy when you can break it.
So the first is that it has
to be identifiable 3rd party.
So, a person that can be, you know their identity, not just random person out
in the world but somebody you can identify and potentially directly warn.
It has to be something that is of serious harm that
could happen to them if you did not warn them.
So a serious disease, a threat to their physical well-being thru
violence, any of these things that would count as a serious harm.
If you did not disclose, if you did not break confidentiality,
there's a high probability that the harm will occur.
So, you know, they're even more push
to make sure that there is disclosure.
And it's taught that the disclosure will actually prevent
the harm so maybe you've tried to convince the patient,
you know, who's disclosed this information
to you, try to convince them well.
We need to, other you don't need to,
you know commit violence for sure
but we need to warn this other person that
there's a harm that could occur to them.
All of those measures have failed. You can't convince the patient.
You've tried other means of warning.
The only way that you can accomplish preventing the
harm to the 3rd party is breaching confidentiality.
So, if you've got all of these criteria fulfilled, these requirements
fulfilled, then it is permissible to breach confidentiality.
Some examples besides, you know, the violent patient example
might be something like a sexually transmitted disease.
You learned the patient's diagnosis, you try to convince
them while you should notify your sexual partner
that they may be at risk of having acquired the sexually
transmitted disease, the patient is unwilling to do so.
One, you might need to report it to the health department
as we've talked about for public health reasons
but if you directly know the identity of the
person it may be permissible for you to do it
if you think that this sexually transmitted
disease could be a serious harm to the patient.
There's one that's a little more
controversial with genetic disorders.
So, you're doing genetic
testing for a patient.
You learn that they have a particular
condition that is inheritable
and now maybe another family member is at risk of getting that
condition and maybe a high probability of getting that condition.
One, you might start with trying to convince the patient why you
should tell your family member of their genetic predisposition,
but failing that it may be permissible for the
clinician to disclose that to other family member.
Some of this is going to be dependent
on the jurisdiction where you practice.
So it's important that you know what
the rules in your jurisdiction are,
whether it's mandatory that you have to
report it or whether it might be permissible
and then you have to make a judgment as to
whether or not all of these criteria are met
and it's important enough that
you breach the confidentiality.
So that's the wrap up of privacy and confidentiality.
First and foremost, protect it.
You know, make sure the personal information you learned from a
patient that you learned in confidence is respected and protected.
There are going to be some instances where
there's a need to disclose that information
whether it's for the patient's interest or others' interest
and some of this is going to be discussing with the patient,
working it out with them, and some rare instances that you need
to breach confidentiality for the interest of other people.
Hope that was informative.
Thank you very much.