Professionalism and Confidentiality

Question 1

What provisions can a doctor practise in accordance with their personal beliefs? (x4)

Answer 1

• Acting in accordance with the law
• Do not treat patients unfairly – discrimination (undermines the justice pillar).
• Do not deny patients access to appropriate medical treatment or services
• Do not cause patients distress

Question 2

What law protects patients from discrimination from medical professionals?

Answer 2

Equality Act, 2010. Prohibits direct and indirect discrimination against patients on the ground of a protected characteristic when they provide medical services.

Question 3

What must a doctor do if they have a conscientious objection to a treatment or procedure that may be clinically appropriate for a patient? (x3)

Answer 3

1. Tell the patient that you do not provide the particular procedure/treatment, being careful not to cause distress. If you mention the reason for your objection, you must be careful not to imply any judgement of the patient. 2. Tell the patient that they have the right to discuss their condition and the options of treatment with another practitioner. 3. Make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you.

Question 4

Can doctors refuse treatment in emergencies?

Answer 4

No. In situations when treatment is necessary to save a patient’s life or prevent serious deterioration.

Question 5

What should healthcare professionals do for patients who request a procedure for religious/cultural reasons e.g. circumcision?

Answer 5

You should discuss with them the benefits, risks and side effects of the procedure. You should usually provide procedures that patients request and that you assess to be of overall benefit to the patient.

Question 6

What should healthcare professionals do for CHILDREN who request a procedure for religious/cultural reasons e.g. circumcision?

Answer 6

You must proceed on the basis of the best interests of the child and with consent. Assessing best interests will include the child’s and/or the parents’ cultural, religious or other beliefs and values.

Question 7

What should you do if a competent and fully informed patient declines treatment?

Answer 7

Respect a patient’s decision to refuse an investigation or treatment, even if you think their decision is wrong or irrational. You must be careful that your words and actions do not imply judgement of the patient or their beliefs and values.

Question 8

What if parents refuse treatment for their child and the child does not have capacity to make a decision?

Answer 8

You must discuss their concerns and look for treatment options that will accommodate their beliefs. If following a discussion of all the options you cannot reach an agreement, and treatment is essential to preserve life or prevent serious deterioration in health, you should seek advice on approaching the court. In an emergency, you can provide treatment that is immediately necessary to save life or prevent deterioration in health.

Question 9

What arguments are there against conscientious objection? (x5) Overall argument?

Answer 9

• OVERALL ARGUMENT: Patient autonomy.
• Insufficiency: if patients have to shop for a doctor that does the service they are entitled, searching for doctors introduces inefficiency and wasting resources.
• Inequity: some patients, less informed of their entitlements, will fail to receive a service they should have received if a doctor refuses a treatment.
• Inconsistency: slippery slope argument. Where do you draw the line between a reason for conscientious objection being a legitimate/illegitimate? Imagine in an epidemic of bird flu or other infectious disease that a specialist decided she valued her own life more than her duty to treat her patients. Such a set of values would be incompatible with being a doctor. But, if self-interest and self-preservation are not generally deemed sufficient grounds for conscientious objection, how can religious or other values be?
• Commitments of a doctor: All doctors agree to sacrifice some of their personal autonomy when embarking on a career in medicine because the duties of the doctor state that we must make care of our patient our first concern e.g. if a doctor declines to perform an abortion, should they be allowed to be become a gynaecologist?
• Discrimination: religious values are sometimes considered ‘special’. However, elevating religious values as reasons more justified to conscientious objection than secular values is discriminatory to secular values – particularly if those secular views are held just as strongly.

Question 10

What are arguments for conscientious objection? (x2)

Answer 10

• Physician autonomy is also enshrined in law. To fail to allow conscientious objection harms the doctor and constraints their liberty.
• Doctors around the world are sometimes asked to participate in situations which are extremely challenging such as assisting in carrying out the death penalty. Conscientious objection provides an important safeguard against being mandated to participate in immoral acts.

Question 11

What are GMC guidelines with conscientious objection and gender reassignment surgery? However?

Answer 11

Doctors cannot refuse because this counts as discrimination. However, you CAN decide not to provide treatment IF you hold a conscientious objection that, for example, it will cause infertility.

Question 12

What is the GMC’s guidance on sharing personal views with a patient?

Answer 12

Doctors may disclose personal beliefs if directly asked by a patient but must not impose their beliefs and values on patients, or cause distress by the inappropriate or insensitive expression of them.

Question 13

What circumstances can confidentiality be broken? (x5)

Answer 13

1. Sharing information with healthcare team
2. The patient consents
3. The disclosure is of overall benefit to a patient who lacks the capacity to consent
4. The disclosure is required by law e.g. court proceedings
5. The disclosure can be justified in the public interest e.g. patient with a STI has potentially infected another patient. Doctor should disclose this information to the potentially infected patient if the patient is not willing to do so.

Question 14

Can you share personally identifiable information with a colleague who is not caring for the relevant patient?

Answer 14

No.

Question 15

What things must you make sure when disclosing information about a patient? (x5)

Answer 15

1. Use anonymised information 2. Be satisfied that the patient has ready access to information that explains that their personal information might be disclosed, and that the patient has not objected. 3. Get patient consent if any identifiable information is shared. 4. Keep disclosures to the minimum necessary 5. Observe relevant legal requirements

Question 16

List the arguments in favour of confidentiality? (x4)

Answer 16

• Consequentialist argument
• Deontological argument (or duty argument)
• Autonomy argument
• Public/private benefits

Question 17

What is the consequentialist argument in favour of confidentiality?

Answer 17

If confidentiality is promised, patients will be willing to be completely honest with their doctors, and to discuss all of their symptoms and past history.

Question 18

What is the deontological argument in favour of confidentiality?

Answer 18

Doctors have a duty to abide by confidentiality: When a doctor gains personal information about a patient there is an implied promise that this information will be kept confidential. There is a moral duty not to break promises. Therefore, it is wrong to breach confidentiality unless we are given permission to disclose.

Question 19

What is the autonomy argument in favour of confidentiality?

Answer 19

Patient has the choice of what happens to their information. Control is an expression of autonomy.

Question 20

What is the public/private benefits of confidentiality?

Answer 20

Confidentiality aids an effective healthcare system. If confidentiality is broken, it not only harms the individual (private), but it also has an impact on the public’s willingness to trust medical professionals and this can harm the health of the nation (public).

Question 21

What is the argument against confidentiality?

Answer 21

We are focusing on the wrong argument. We should not be focusing on confidentiality between a doctor and a patient; instead, we should be focusing on protection of records and ensure proper use of medical records (matters outside of the doctor-patient relationship).

Question 22

Example of ethical argument and confidentiality: Immigrant seeks medical attention with pneumonia. You should inform your Trust’s overseas administration officer as you suspect your patient is not entitled to NHS care. What reasons are there for and against informing the officer?

Answer 22

• Consequentialist argument. BUT reporting to the authorities may help reduce illegal immigrants using the NHS and most patients are not illegal immigrants, so informing the authorities won’t reduce trust in the medical profession.
• Autonomy argument. BUT providing healthcare to immigrants is a drain on the NHS, which may result in harm to others who are entitled. Therefore, as harm is risked to entitled patients, it is acceptable to override autonomy.
• Duty argument: your primary duty is to the patent.

Question 23

You are a medical student and a patient shares information about their care that they want you to keep confidential. What do you do?

Answer 23

You should explain to the patient your role within the team and the importance of sharing that information, giving appropriate reassurance to the patient that the information will remain confidential within the medical team and discuss the issue with a senior colleague.

Question 24

Why does confidentiality still apply after death?

Answer 24

If confidentiality did not exist after death, patients would be less willing to divulge sensitive information for fear of repercussions on their legacy. Not trusting a doctor to share sensitive information can have implications on health.

Question 25

What common circumstance after death is confidentiality broken?

Answer 25

Death certificate is a public document – including cause of death.

Question 26

What is the importance of sharing information with a healthcare team? (x2)

Answer 26

SAFE and EFFECTIVE care. Without access to a patient’s records, the patient could be put at risk.

Question 27

How does consent work with sharing information for direct care?

Answer 27

It’s an OPT-OUT framework: Consent is IMPLIED as most patients know that their information is shared within the care team. You should share information unless the patient OBJECTS.

Question 28

When should implied consent about sharing medical information be assumed? (x4)

Answer 28

• When you are accessing the information to support an individual’s care.
• Information is readily available to patients explaining how their information is used and that they have the right to object.
• You have no reason to believe the patient has objected.
• You are satisfied that anyone you disclose personal information to understands that you are giving it to them in confidence.

Question 29

If a patient objects to sharing information with the healthcare team, under what circumstances can you ignore this objection? (x2)

Answer 29

When disclosure of information would be justified in the public interest, or it will benefit the patient who lacks capacity to make the decision.

Question 30

When can you share information about a patient to relatives?

Answer 30

Early in the patient’s care, you should establish who they want to share information with and abide by their wishes where they have capacity. If they do not have capacity to make a decision, it is reasonable to assume that those closest to the patient should be kept informed.

Question 31

Early in the patient’s care, you should establish who they want to share information with and abide by their wishes where they have capacity. If they do not have capacity to make a decision, it is reasonable to assume that those closest to the patient should be kept informed.

Answer 31

You should try and persuade them to allow an appropriate person to be given relevant information about their care. If the patient still does not want you to disclose information, but you think it would be of overall benefit to the patient, you may disclose information to relevant parties. In such cases, you should tell the patient before disclosing the information.

Question 32

How should patient information be shared for teaching purposes?

Answer 32

Anonymised information is acceptable (but removing name, age and address is unlikely to be enough). You can disclose identifiable information with patient consent.