Case and Commentary
Jan 2005
The obligation to maintain patient confidentiality dates back to the Hippocratic Oath and remains essential to the practice of medicine. Maintaining confidentiality produces the conditions necessary for optimal medical practice. Specifically, patients who trust their physician to maintain confidentiality will be more likely to share important personal information (eg, whether or not they use drugs) that can help attain a more accurate diagnosis and effective treatment plans.
Opinion 5.05, "Confidentiality"
The information disclosed to a physician during the course of the relationship between physician and patient is confidential to the greatest possible degree. The patient should feel free to make a full disclosure of information to the physician in order that the physician may most effectively provide needed services...
The obligation to safeguard patient confidences is subject to certain exceptions which are ethically and legally justified because of overriding social considerations...
When patients pose threats of harm to specific third-parties or to the public health, physicians may have a duty to breach confidentiality. These threats can take a variety of forms, including intended violent acts as well as irresponsible or malicious actions arising from the patient's medical condition. Specifically, patients who are HIV positive may put third parties at risk through a variety of behaviors including needle sharing and unprotected sexual intercourse.
Opinion 2.23, "HIV Testing"
The confidentiality of the results of HIV testing must be maintained as much as possible and the limits of a patient's confidentiality should be known to the patient before consent is given.
Exceptions to confidentiality are appropriate when necessary to protect the public health or when necessary to protect individuals, including health care workers, who are endangered by persons infected with HIV. If a physician knows that a seropositive individual is endangering a third party, the physician should, within the constraints of the law: (1) attempt to persuade the infected patient to cease endangering the third party; (2) if persuasion fails, notify authorities; and (3) if the authorities take no action, notify the endangered third party...
A patient's HIV status should remain confidential, except under the clearly defined circumstances where disclosure is necessary for safeguarding public health or identifiable third parties. The reporting requirements differ from state to state, and physicians should be aware (and should make patients aware) of what information will be reported.
Opinion 2.23, "HIV Testing" clearly states that "the limits of a patient's confidentiality should be known before consent [to testing] is given." Dr. Macklin failed to inform Mr. Jonsen of the limits of the obligation of confidentiality in this kind of case. It is not clear whether doing so would have made a difference in Mr. Jonsen's decisions or reaction, but Dr. Macklin slipped up on this obligation just the same.
The physician's duty to report is not limited to communicable diseases (like STDs). When physicians have reason to believe that individuals may be a threat to the welfare of others or have been the victims of violence, they should inform appropriate authorities. Physicians have this duty to report because of their responsibility to the public good. The following Opinions articulate the features of this responsibility.
Opinion 2.02, "Abuse of Spouses, Children, Elderly Persons and Others at Risk"
The physician should comply with the laws requiring reporting of suspected cases of abuse of spouses, children, elderly persons, and others....Absent such legal requirement, for mentally competent, adult victims of abuse, physicians should not report to state authorities without the consent of the patient.
Opinion 2.24, "Impaired Drivers and Their Physicians"
Physicians should assess patients' physical or mental impairments that might adversely affect driving abilities...The physician must be able to identify and document physical or mental impairments that clearly relate to the ability to drive; [and] the driver must pose a clear risk to public safety...[However], the determination of the inability to drive safely should be made by the state's Department of Motor Vehicles...Physicians should disclose and explain to their patients this responsibility to report...Physicians should protect patient confidentiality by ensuring that only the minimal amount of information is reported and that reasonable security measures are used in handling that information.
