The emergency department in the hospital nearest a certain college campus has admitted four 22-year-old college seniors in the past half hour.
Case A. The first senior is being seen for pharyngeal gonorrhea, a venereal disease often associated with homosexual activity.
Case B. The second senior is being tested for an apparently intentional antihistamine overdose. He is doing well, and after several hours of observation, he will be referred for psychiatric care.
Case C. The third senior was brought in by ambulance, after having been injured in an automobile accident. He has a neck strain, but his x-rays are negative, and he will be released shortly.
Case D. The fourth senior was also involved in an automobile accident. He is unconscious and is in critical condition with multisystem injuries.
The mothers of these students call long-distance to inquire about the medical conditions of their sons.
What information, if any, should the physician give in each case? Does upholding patient confidentiality depend upon the nature or the severity of the illness?
What information, if any, should the physician give to a caller other than the parent?
What if the patient does not have any family, and a friend inquires about his condition? What if the inquirer is a reporter from the local newspaper?
Commentary
Few moral rules in the health professions are as widely accepted as those stipulating that confidentiality and privacy should be respected in relationships with patients.
Without such rules, it is feared that people would hesitate in seeking medical help for potentially embarrassing or stigmatizing problems and that patients would withhold personal but medically relevant information from health care providers.
In addition to these utilitarian justifications for rules of confidentiality and privacy, the injunction to respect the autonomy of patients demands respect of patient confidences and thus provides an additional, if not primary, moral warrant for such rules.
It also assumes that privacy is a basic human need and thus that respecting a patient’s privacy is a fundamental moral obligation.
The standard “operational definition” of the rule of confidentiality is that health professionals may not disclose information about a patient to other parties without the patient’s consent.
Exceptions to the rule may be morally permissible (depending on the circumstances), but the burden of moral proof falls on those who would violate it.
It is arguably the case that confidentiality and privacy rules are somewhat less binding in emergency medicine, where the patient-physician relationship is less well established.
APPLICATION OF PRINCIPLE OF CONFIDENTIALITY TO CASES A AND С
When applied to Cases A and C, the rule of confidentiality yields a clear answer: no specific information about the son’s medical condition may be disclosed to the mother without the son’s permission.
It is a simple matter for the physician to put off the mother’s initial inquiry and return her call after having checked with the son to ascertain his preferences.
Even in Case C, where there is no obvious reason to think a son would wish to keep his medical situation from his mother, it would be inappropriate for the physician to act on this presumption.
It is, for example, possible that the son would not wish his mother to be informed about his involvement in an automobile accident because his driving habits are currently at the root of a major family conflict.
The rule of confidentiality does not, of course, require the physician to be insensitive to the anxious concerns of a worried mother: carefully formulated words of general reassurance can be conveyed without violating the son’s privacy.
In general, the application of the rule of confidentiality to Cases A and С is unaffected by whether the party requesting information is the patient’s friend or the news media, except, of course, that the news media — unlike the mother or even the friend — is not entitled to a thoughtful, compassionate response from the physician.
It is a widely recognized practice of hospitals to disclose general reports of patients’ medical conditions without the specific, prior authorization of patients (for example, the patient is in serious condition).
These reports do not violate the privacy or confidences of patients and are usually sufficient to satisfy the legitimate interests of the news media in the case of public events like crimes or automobile accidents.
INAPPLICABILITY OF PRINCIPLE OF CONFIDENTIALITY TO CASE D
The rule of confidentiality does not apply to Case D. Because the patient is unconscious, it is not possible to ascertain the patient’s preferences as to disclosure of information.
Also, because the patient is in critical condition and may never regain consciousness, a decision about disclosure cannot reasonably be deferred.
Here, the physician is not violating any moral rules in providing detailed information to the mother; indeed, the physician may well be morally obligated to do so.
APPLICATION OF PRINCIPLE OF CONFIDENTIALITY TO CASE В
Case В is more complicated. Let us assume that the physician does not have an adequate data base from which to draw any solid conclusions about the patient’s competence or psychiatric status.
The simplest course for the physician to follow is to abide by the rule of confidentiality: if the patient does not want his mother informed of his apparent suicide attempt, the physician does not disclose this information.
This may, indeed, be the most morally appropriate response, particularly if there is any reasonable doubt about the intentionality of the overdose.
However, even if this is clearly a case of attempted suicide, the physician does not have a moral obligation to tell the mother what has happened over the son’s objection.
The interesting question is whether it would be morally praiseworthy for the physician to do so, in the hope of preventing future harm to the patient.
Unfortunately, the emergency physician is not in a good position to make a judgment about the likelihood that informing the mother will actually assist the patient.
For this reason, if for no other, the prudent response would be to follow the morally acceptable course of respecting the son’s wishes.
