Ethics of Confidentiality in Mental Health

This assignment delves into the complex ethical considerations surrounding conditional confidentiality in mental health practice. It examines the tension between patient autonomy and the duty to protect others from harm. Key concepts discussed include informed consent, the influence of cultural perspectives on decision-making, and the legal framework governing confidentiality in mental health settings. The assignment requires critical analysis of various ethical theories and their application to real-world scenarios.

Health Ethics
Autonomy and Paternalism, confidentiality and consent
15-Jan-18
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Health Ethics
Ethics are the values which guide the actions of the individuals, and are based on the morals of
such individual. These morals and values channel the acts undertaken by the people. These ethics
translate in the daily lives of people and decide upon the manner in which a person acts.
Naturally, these also shape the manner in which the work is done by the individuals (Smith,
2008). When it comes to healthcare, the role of the individuals, in adhering to the ethical values
in enhanced. This is because the relationship between the patients and the healthcare
professionals is one of trust and care; and due to the dominating position of the healthcare
professionals over their patients and the ones related to the patients, it becomes utmost important
that the ethics are properly followed. This is particularly due to the patients having certain rights
in the kind of treatment they get and the duty of the healthcare professionals to respect the
human rights of their patients. One of such rights is autonomy, where it is stated that the patients
need to have the freedom of deciding upon their lives, which includes the medical treatment they
get, and the like. However, a controversial issue in this regard is offered through the concept of
paternalism. This concept provides that there should be the right with the healthcare
professionals to interfere in the liberty of actions of an individual owing to their welfare,
happiness, interests, values, or good (Murgic, et al. 2015). The difference between the two, in
terms of healthcare ethics is elucidated below. Along with the clash between the two concepts,
the discussion would also highlight the significance of consent and confidentiality in context of
healthcare. The overall purpose here is to highlight the key points which are related to healthcare
ethics.
Consent, or is aptly known as informed consent, in context of healthcare industry, is referred to
the permission given by the individual, after they come to know about all of the facts of the case
and the possible consequences of undertaking such actions. In doctor-patient relationships,
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informed consent holds major significance as the patients are required to be given the entire facts
of their case and the possible results of their treatment, in order for such patient to given their
informed consent to a particular treatment. This allows the patients to analyse all the facts and
weigh in the pertinent risks, before they opt for a particular treatment suggested by the healthcare
professional (Wear, 2012). This consent is based on the clear understanding, as well as, on the
appreciation of factual background, its implications, and the consequences of going forward with
the proposed action. Particularly in context of ethics, a proper and informed consent has its roots
in the dignity of any individual. This means that the people need to be provided with the
adequate reasoning facilities for them to give their consent on the basis of the facts which are
relevant to them (Brown, 2011).
The concept of consent is based on the basic human rights and on the ethical principle of patient
autonomy. The patients have all of the freedom in order to make a decision on what happens to
their body and for gathering the relevant information before a surgery, test or procedure is
undertaken. A patient cannot be coerced in any manner; the doctors simply have to act as the
facilitator of the decision making of the patients. Consent is not only stemmed in ethical
principles, but in the legal ones as well. Where the informed consent of the individual is not
taken, and the patient is touched by the doctor, it would be treated as battery, which is a physical
assault in legal terms, and is also punishable. This makes taking of the consent very crucial in the
daily physical examinations. This makes the mutual communication between a patient and doctor
instrumental in context of the choice, authorization or permission of the former for acting the
latter in a specific manner (Rao, 2008).
Another crucial element related to consent is the difference between an implied and express
consent. The implied consent, as the name suggests is one which is implied through the conduct
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of the patient; and the express consent is the one procured expressly from the patient. The
difference between the two can be better elucidated through respective examples. When a patient
goes in the chamber of the doctor and they express their problems to the doctor, there is an
implied consent to the doctor for undertaking the general physical exam and for carrying the
routine investigations. However, when it comes to the express consent, the same is needed for
intimate examinations. For instance, where an invasive test or a risky procedure is to be
undertaken, a specific express consent has to be taken from the patient, which can take form of
written consent or oral consent (Snyder and Leffler, 2005). It remains preferable to take written
consents in such cases where long term follow up is required, in addition to the procedure being
high risky intervention, surgery or cosmetic procedure. In order to gain the informed consent of
the patient, crucial information has to be disclosed which involves the need for further testing,
the condition of patient, results of treatment, different available options, possible complications,
expected outcome, duration and cost of treatment, and the possible benefits and risks of such
treatment (Heywood, Macsakill and Higgins, 2010).
The concept of consent is also aligned based on the ECHR, i.e., the European Convention on
Human Rights. Under article 3, it is specifically provided that a forced treatment which is given
against the wishes of an individual would be deemed as the breach of this article, as this article is
related to the inter alia inhumane and degraded treatment (Byrne, 2012). In Ireland, the patient
doctor relationship is deemed as a privileged one and is dependent on the trust of the patient in
professional conduct of the doctor. This is the reason for issuing a Guide to Professional Conduct
and Ethics by the Medical Council for the registered medical practitioners (Medical Council,
2018).
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Another important concept in health ethics is autonomy v paternalism. Patient autonomy is the
basic principle in the concept of professional medical ethics. The ability of recognizing and
fostering the same has different dimensions and has been considered of vital significance in the
clinical competency of the physicians. Beauchamp and Childress (2001) accepted autonomy as
amongst one of the four principles of medical ethics, in addition to justice, beneficence and non-
malfeasance. As stated in the introductory segment, autonomy is related to the self-determination
or the self-rule, where the patient gets to decide on the treatments they get in a free and
independent manner (Tai and Tsai, 2003). Paternalism on the other hand, is just the opposite of
autonomy, where the doctors are said to act as the moral agent of the patients and make the best
decisions for the patients, even when they can make such decisions for themselves. This is
stemmed from the fact that the doctors are experts who can easily make the judgments and
decisions as they know what has to be paid attention to and what has to be ignored. This brings
forth an ethical dilemma for the healthcare professionals, where they have to choose between
providing the patients with the requisite autonomy or giving the doctors the paternalistic freedom
of choosing what is best for patients (Lepping, Palmstierna and Raveesh, 2016).
In medical ethics, it is necessary to give more significance to paternalism in place of autonomy.
To prove this, an example is put forth here. A 32 year old pregnant lady went for a vaginal
delivery. Before this pregnancy, she had two babies through emergency caesarean section. And
the second baby had been born merely one year ago. As a result of this, the doctors wanted the
wide to avoid taking any sort of risk and wanted her to deliver the baby through a caesarean
section. Both the husband and the wife were attempted to be convinced by the medical staff;
however, they did not agree with the same. As a result of this, the patient was sent back home in
order for trail of normal labor. After a period of two weeks, she returned to the hospital with very
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strong pains and when his delivery was taking place the uterus was ruptured. The doctors were
able to deliver the baby in a normal manner but the mother had to be transferred to Intensive
Care Unit in order to observe her closely. However, she could not be saved and died a few weeks
later (Sayani, 2015).
This case helps in raising certain good questions. The very crucial one is whether medical
paternalism could have saved the life of the patients? And whether in this case the principle of
autonomy was justified? This highlights the ethical dilemma where respecting the autonomy of
the couple, the women was exposed to complications, which ultimately resulted in her demise.
Had the healthcare professionals taken the decision, there would have been a breach of autonomy
of the patient. To put emphasis on paternalism, another example can be put forth. This is the
case of suicide, particularly in cases of individuals suffering from psychiatric illness. An
individual suffering from psychiatric illness, particularly who are at the risk of committing
suicide, cannot be given their autonomy. If the autonomy is given to such patients, they would
commit suicide. Even though this could be deemed as giving the individuals the freedom of
making their own choices, it would not be ethical on part of the doctor to allow the patient to be
given their autonomy when they know this would result in the patient killing themselves. This is
where the fight between the two concepts of autonomy and paternalism takes place. This is the
situation where the healthcare practitioners face the ethical dilemma of choosing between the
two concepts (Ho, 2014).
In this regard, when psychotherapy is performed by the psychiatrists, they initially have the
tendency of withholding certain information from their patients. An example of this is that they
would not tell their patients the psychodynamics which they infer. In place of this, the
information is titrated over a course of time. This is to safeguard the patients from getting
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overwhelmed and from not returning to get the relevant treatment, which is important for them.
However, there are psychiatrists who feel that full information should be shared with the patients
and that the patients should be given the time to share this information, even when doing so
results in greater harm being caused to the patients. In terms of ethics, the reasoning for sharing
of information with the patients could be justifiable and even obligatory in context of increasing
their autonomy. This is deemed as more important value in general in place of attaining benefit
for the patient by withholding such information from them, even when the information may lead
to the patient making the choice which is against their best interest. This information shows
transparency and gives equality to the patients to level the playing field (Howe, 2008).
A very apt question was raised by Kongsholm and Kappel (2017) regarding the consent being
based on information or trust. The research conducted by them provided that in case of
participants indulged in medical research, they do not rely upon the information provided to
them to give their consent, but instead over the trust which they hold in the researching
enterprise or the researcher. The Mental Health Act, 2001 puts an obligation on the healthcare
professionals to inform the patients properly about the treatment they are getting, in order for
them to gain full knowledge on their situation. This consent is required save for such situations
where the opinion of the consultant psychiatrist feels that the treatment is required for the safety
of the patient and for alleviating their condition, particularly when the patient is incapable of
giving their consent. In essence, here the legislation also gives preference to paternalism over
and above autonomy. The decision on the capability of the patient to make decisions for
themselves remains contested. This is because it raises questions on the patient being held
capable of making the decision, as this is something which is subjective in nature (Donnelly,
2016).
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Gillick v West Norfolk & Wisbeck Area Health Authority [1986] AC 112 presents a landmark
decision where a number of complex legal issues regarding the consent of a minor person were
raised. In this case, Mrs Gillick had sought and attained contraceptive advice from a local doctor
while she was below the age of giving lawful consent to intercourse. This was based on the
guidance which had been issued by the relevant Department of Health and Social Security. She
sought a declaration from court asking for the guidance of department to be deemed as illegal
and an inference with the paternal duties and rights. The House of Lords had to decide on the
extent of parental control over their minor child and whether the child could give consent to
medical treatment or contraceptive advice against the knowledge of wishes of their parents. The
declaration was dismissed by the court. The consent for treatment could only be given when the
person could be deemed as intelligent and sufficient enough to understand what has been
proposed (HRCR, 2018). Again, this highlights the subjectivity in making the decision on the
person holding the right to given their consent and continues the clash between autonomy and
paternalism. Though, it is a victory for advocates of adolescent autonomy (Cave, 2014).
However, one should not forget that this was again based on the question of competence, of a
person making decision for them, which is the theme of paternalism.
Another substantial point in medical ethics is confidentiality. Confidentiality in healthcare field
is of utmost importance as the patients share their personal information in a routine manner with
the healthcare providers. In such cases where the confidentiality is not maintained, the data of the
patients would not be protected and this would result in the trust present in the physician- patient
relationship being diminished. This would make the patients less prone to sharing of the
information, particularly the materially sensitive one, which would impact the care provided to
the patients in a significant manner. Confidentiality is a necessity for creating a trusting
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environment where the patient privacy is not only respected but is also protected and
encouraged, which allows the patients in being honest in their healthcare visits. This also has the
capability of increasing the willingness of the patients for seeking care. In cases where the
patients have a stigmatizing condition, which is related to psychiatric health concerns, public
health, reproductive or sexual health, the confidentiality helps in assuring that the private
information is not disclosed to any person, without their consent being given for the same
(Fisher, 2013). This is aligned with the Data Protection Acts 1988 and 2003, where the privacy
of individuals is to be protected (Department of Health, 2018).
Confidentiality continues to be a key point which ensures that the patients trust the doctors. The
moral basis of it is consequentialist owing to the fact that it is meant to improve the welfare of
the patients. In essence, it is required for protecting the confidence of general public and for
securing the public health. This ethical principle has been upheld for centuries through a
Hippocratic Oath. The reason for the same is that in modern medicine, medical confidentiality is
not absolute. And the same can be breached with consent, through law, and in public interest
(Blightman, Griffiths and Danbury, 2014). Again, confidentiality not being absolute touches the
discussion carried earlier in context of interplay of autonomy v paternalism and consent. Where
there are concerns regarding the safety of another person, the medical information of a patient
can be made available to a person who would normally not be provided with such information.
In doing so, the good of the patient is given supremacy, and the patient is safeguarded from
credible threat of harm. Here a good enough reason has to be provided to show that the
individual is in serious danger and the medical information is crucial. For instances, in cases of
homicidal ideation, a psychotherapist or physician can be made to provide the details of an
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individual prone to harming others. Again, where there is a requirement by the law to provide the
medical information in certain situations, the same has to be done (Bord, 2018).
To bring the discussion to its conclusion, the preceding parts carried a discussion on the three
most significant aspects which are crucial in the healthcare ethics. These three are consent, a
clash between autonomy and paternalism, and confidentiality. The discussion started with
discussion on what exactly informed consent is. Informed consent requires the patient to be
provided with all the relevant information in order for them to make the choice of going forward
with a medical procedure or treatment, or to avoid the same. The above carried discussion
highlighted how there is a constant clash between autonomy and paternalism and different
examples were given to show the supremacy of paternalism over autonomy. This debate is due to
the difference in the two concepts where autonomy provides that the patients should be given the
choice of making decisions for them, whilst paternalism shows that the experience and the
knowledge of the doctors or the healthcare professionals is enough for them to make the wise
choice even on behalf of the patient. Through the example of the pregnant lady, who had to lose
her life as a result of autonomy being given preference, the supremacy of paternalism was
supported. The last aspect discussed above was the due weight being given to the confidentiality
of the patients in order for them to trust the healthcare professionals and for them to disclose
everything without having to fear for the information being misused or wrongly distributed.
However, even the confidentiality of patients is shown to be conditional. Thus, there are a
number of instances where the medical professionals are presented with ethical choices, and
where there continues to be clash between what is right and what is wrong, owing to the
diversified views of similar issues.
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