How can confidentiality be a dilemma

Obviously, the acceptability of breaching confidentiality goes back to the magnitude of the threat to the third party. Therefore, the magnitude of the threat should be defined completely to prevent ambiguity and moral complexity. Magnitude of the threat depends on the risk severity. Iran legal system mandates physicians and other hospital staffs to report child abuse and every other type of abuse as well as contagious diseases.

Child abuse or sexual violence causes physical and mental distress in short and long-term. The victims will suffer stigmatization, discrimination and get more sensitive to violation and sometimes become a subject of more violations.

In this situation, the victim regardless of age may seek real protection of health care system especially the physicians. Reporting any case of abuse and disregarding confidentiality in report may diminish the trust and sensitizes the victim to more violations.

In the draft, we differentiate between different types of consents drawn from patients according to the severity of their diseases, for example, consents obtained from incapacitated patients. There is a need, however, to make further investigation into compilation of an ethical guideline for reporting child abuse adapted to our local condition, cultural and religious principles. Adolescents have the right to confidentiality the same as adults. Privacy has an impact on adolescents-physicians relationship and lack of confidentiality could be their major obstacle to seek for healthcare Accordingly, their information should be kept confidential in clinical settings.

For children of less than 18 there would be a challenge as we do not know their degree of maturity consistent with their autonomy and ability to decision making, so keeping their information confidential, putting them responsible, and not informing their parents about their health-related issues would be problematic.

The child who understands the diagnosis was considered and treatment and makes decision as competent enough who has the right to confidentiality From cultural point of view, Iranian children are under full parental support by their parents until marriage and it is likely the parents be present at all occasions in clinical settings with their child. The adolescents who seek health care and report their engagement in high-risk behaviors so they might have concerns about confidentiality The fear of breaching confidentiality is the major reason for not seeking health care in adolescents 22 , 23 especially the high-risk ones Therefore, provision of confidential health care services is necessary for them.

They would provide confidential contraceptive services to adolescents without informing their parents Confidentiality concern can be a reason for waiver of health care and increase the restrictions of confidentiality may decrease health care use in adolescents which has harmful health consequences Considering legal context, application of well-set procedures and requisite relationship with adolescents was necessary for respecting confidentiality and will mitigate obstacles for adolescents to refer to health care system Therefore, modification of administration based on IT security and defining different levels of access for different users is highly recommended.

Because improving computer knowledge has positive effect on complying with IT security, some suggest continued education about confidentiality and continuous inspection for better confidentiality implication Therefore, using smart cards, and saving files as password protected are recommended Some of the challenges we discovered are multidimensional and need more investigations from ethical, legal and social aspects.

Of that confidentiality in relationship with social media, confidentiality in child abuse, designation of system audit, confidentiality in detention setting, and confidentiality after death have not been included in our draft. In fact, this draft is the first ethical guideline to confidentiality in clinical settings to address the most common ethical challenges and the scope of confidentiality; however, compilation of the later drafts for confidentiality in relationship with social media and confidentiality in child abuse is underway.

Of course, some of the other actions are required to set the goal of changes in national laws which are beyond the scope of this study. Respect to confidentiality goes back to respect for autonomy and human dignity. According to Iranian law breaching confidentiality is forbidden while in some occasions in medical practice it is unavoidable. Therefore and based on our results we compiled a guideline to shape ethical decision making when facing with ethical challenges in practice.

So the compiled guideline helps medical professionals to have an ethical approach toward confidentiality. However the multidimensional nature of the challenges of confidentiality in medical practice necessitates further investigations from ethical, legal and social aspects. This study was carried out in collaboration with the scientific group of Philosophy, Ethics, and Biosciences of the Academy of Medical Sciences; we had no financial sponsor for this study.

Conflict of interest. National Center for Biotechnology Information , U. Iran J Public Health. Author information Article notes Copyright and License information Disclaimer. Received Mar 14; Accepted Aug This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC.

Methods: This study was conducted in three phases including literature review, qualitative study semi-structured interview and focus group discussion. Results: The content analysis of the interviews presented 3 main themes indicating problems in maintaining confidentiality in clinical setting including management issues, organizational ethics and physician-patient relationship.

Conclusion: Based on the results a draft guideline in confidentiality in clinical setting was prepared and finalized in focus groups discussions. Keywords: Confidentiality, Clinical setting, Confidentiality guideline, Medical ethics. Introduction Since Hippocrates, confidentiality has been presented as 1 cornerstone of ethics in healthcare. Data analysis All the interviews were transcribed verbatim more than three times to get familiarize with data through frequent readings and note takings.

Results Phase one: Gap analysis The results of the literature review are summarized in Fig. Open in a separate window. The framework for interview based on the results of literature review. Phase two: Interviews Using a professionally representative sample of clinical specialists including 2 gynecologists, 3 pediatricians, 2 internists and one endocrinologist, this phase was conducted.

Table 1: The challenges of confidentiality in clinical practice. Challenges in Management Insufficient law and lack of regulations have left ethical challenges of management unsolved. Challenges in Organizational ethics The other main problem in our health system is the secure process of electronic health recordings. Phase three: in-depth discussion about themes of interviews through FGD, compiling the preliminary draft of the guideline In the last phase of this study, all categorized challenges guided us to prepare the draft of the ethical guideline for keeping confidentiality in clinical settings.

Discussion Generally, respect to confidentiality has not been maintained along with developments in technology. Conclusion Respect to confidentiality goes back to respect for autonomy and human dignity. Acknowledgements This study was carried out in collaboration with the scientific group of Philosophy, Ethics, and Biosciences of the Academy of Medical Sciences; we had no financial sponsor for this study.

Footnotes Conflict of interest The authors declare that they had no conflict of interest. References 1. Confidentiality: good practice in handling patient. Mechanic D, Meyer S. Concepts of trust among patients with serious illness. Soc Sci Med , 51 5 : — Log-in Members Forums Register. Confidentiality is seen as a fundamental ethical principal in health care and a breach of confidentiality can be a reason for disciplinary action.

Dilemmas around confidentiality arise when the principle of confidentiality is in possible conflict with other ethical principles such as avoiding harm to the patient or others. Issues around confidentiality may be brought to a clinical ethics committee or group in the form of individual cases or in considering hospital policies.

How will you strategize what happens next, e. What if her mother asks what tests you are doing? Is it ever appropriate to violate the duty of confidentiality? If so, under what conditions? Confidentiality is a prima facie duty. It may be validly overridden by more compelling obligations. In such cases one is obligated to violate confidentiality in order to fulfill a stronger obligation.

However, the burden of proof is always on the one who seeks to justify the breaking of a confidence. Confidentiality is limited in cases where others may be harmed significantly if the confidence is kept. Respect for autonomy does not extend to allowing harm to be done to others. Factors to be weighed carefully include the extent and type of harm that has been confided to you rape or murder vs. Will breaking the confidence prevent the harm? Are there any less intrusive alternatives that would prevent the harm and not require breaking confidentiality or some other ethical obligation?

One must always seek an alternative way of dealing with the problem that might allow you to keep confidence. Every effort must be made to get the person's consent to reveal what needs to be revealed. If people are at risk of serious harm and disclosure is necessary to prevent that harm and there is no less intrusive alternative than disclosure, disclosure is justified.

If confidentiality must be broken, only those with an absolute need to know should be given access to that information, and only that information that is needed to prevent harm should be revealed. In most cases, patient should be notified that confidentiality is to be violated.

What are some examples where breaking the rule of confidentiality might be justified? Beyond mandatory reporting, one's duty to protect others when your patient has an infectious disease is usually discharged by warning the patient that they are at risk to others and telling them how they can prevent spread of the disease to others.

When someone says that they are going to hurt someone else Certain conditions that pose a danger to other people and the patient refuses to act responsibly These conditions may include driving under the influence; promiscuous HIV-infected person having unprotected intercourse; an airline pilot with uncontrolled seizures. The patient had an accident and injured a passenger. Laws governing whether reporting of these situations is mandatory vary from state to state.

Child abuse Duties are to the child. To report parents is not to break confidentiality, but to uphold your duty to give priority to the best interests of the child.

State laws require healthcare providers to report suspected neglect or abuse to child welfare authorities. What about harm to self? Is your feeling that the adolescent might harm herself or that she might later regret her decision sufficient reason to break the rule of confidentiality? Adolescents should be encouraged to consult with parents about decisions. If you decide you must break confidentiality, what are your obligations to the adolescent patient?

Notify them of your obligation to make the revelation. Explain the reasons you feel obligated to break confidentiality. Offer an apology that you cannot maintain confidentiality. Offer them the opportunity to make the revelation themselves in your presence. If you decide to maintain the confidentiality of your adolescent patient, what are some of the ways confidentiality may not be maintained?

In this case, the girl was notified that her pregnancy test was positive and persisted in her request that her mother not be told. Does she need to know about other ways her parents may find out about the test result even though you have promised not to divulge that information without her permission? If she is covered by her parent's insurance, they will receive a bill. The bill might be itemized, including some mention of a pregnancy test.

If her parents were to request a copy of her medical records, they would likely receive all of the information it contained. Many offices have no strategy for identifying information in the medical record that the adolescent would have wished to remain private.

Conclusion with Suggestions Have a standard discussion with all adolescents at the beginning of a visit warning of limitations on your ability to maintain confidentiality : "What you tell me here is between you and me.

That bill may have the names of tests that we do today…" If there is no mechanism in place to restrict access to the records of adolescent patients, they should be warned that parents may have access to their records if they request them , and that you may not be able to prevent that possibility even in states that respect minors' desire to have records not be revealed to parents, it may happen inadvertently. Confidentiality and Adolescents 1. Case Discussion This instructor's guide was developed by Douglas S.