The Ethical Case for Confidentiality

By Gary T. Chiodo, DMD, FACD and Phyllis Beemsterboer, EdD

 

All health care providers are well-aware of the legal protections extended to patient information via the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.  With few exceptions, all information that patients provide to us in the form of their medical history and all data related to the care we deliver to them are protected by the HIPAA rules and may not be released to any third party without patient consent and authorization.  While HIPAA may impose strict legal parameters on how patient information must be protected and how it may be released, there are ethical obligations that provide even more persuasive arguments for the bond of doctor-patient confidentiality.  These ethical obligations are based in the ethical principles of respect for autonomy and nonmaleficence.

Respect for autonomy is the ethical principle that allows, with few limitations, patients to determine what will and will not be done to their bodies.  In normal health care practice, patient autonomy is facilitated and respected through the process of informed consent.  The well-informed patient who has capacity to consent has the right to select from various treatment options, the treatment or treatment plan that is most concordant with his/her values and wishes.  Because the informed consent process is essential in this dynamic, health care professionals must collect and analyze complete information about the patient.  For example, surgical options for repair of a periodontal defect may very well change if the dentist knows that the patient has a bleeding problem.  Plans to remove teeth may be mitigated by a history of bisphosphonate therapy.  In cases like these, patient autonomy cannot be truly facilitated and respected unless the dentist has complete and accurate information about the patient’s medical conditions and history.  If the patient is not entirely comfortable with complete disclosure because he/she doubts that confidentiality will be respected, then important information may be withheld.  When this happens, not only will the patient’s autonomy be compromised, but the dentist’s obligation of nonmaleficence, or avoiding harm to the patient, will be in jeopardy.  While most patients would not be reluctant to reveal a bleeding problem or a history of bisphosphonate therapy, some may hesitate to reveal things they consider to be embarrassing or intensely personal.  For instance, the patient who is receiving treatment for mental health issues or chemical dependency may opt to omit that from the medical history out of concern that it will not be treated with strict confidentiality.  The male patient who is using a phosphodiesterase-5 inhibitor on occasion, may decide to leave that out of his medical history so he does not need to worry about who may have access to that information.  A young woman who takes a hormonal contraceptive may decide that her dentist simply does not need to know that.  While we are well-aware of the potential harms that may come to patients when we do not have complete medical information, patients are less likely to appreciate those harms or, if they are aware of them, may simply decide to keep the information private and accept the risk.

Part of the challenge in obtaining complete and accurate medical information from our patients comes from making sure they understand why we need this information and this process takes chairside time.  However, another important part of the challenge is in ensuring that they trust us to keep it strictly confidential.  If we are not successful in creating that trust, critical information may be withheld and we will not be able to meet our ethical obligations of respect for autonomy and nonmaleficence.  In the best case scenario, breaching confidentiality will result in a patient who feels betrayed and goes elsewhere for care.  In the worst case scenario, the patient will develop a lack of trust in other health care providers, will withhold vital information, and will be seriously harmed.  If we emphasize the protections that we afford their personal information and assure them that they may trust us to keep it strictly confidential we are honoring our ethical principles and serving our patients best.

 

 

Gary Chiodo, DMD, FACD is currently the interim dean at OHSU School of Dentistry. Most recently, he served as the Chief integrity Officer for OHSU, a position he held for 10 years. He is a professor of Community Dentistry and Association Director of the Center for Ethics in Health Care. Dr. Chiodo received his Certificate in Health Care Ethics form the University of Washington School of Medicine in 1992.

 

 

 

Phyllis L. Beemsterboer, MS EpD, FACD is a Professor and Associate Dean for Academic Affairs in the School of Dentistry at OHSU in Portland. She is and associate director in the Center for Ethics in Health Care at OHSU and co-chairs the inter-professional ethics education program. Her research interest is in bioethics education and she is currently president of the American Society For Dental Ethics, a special section of the American College of Dentists.

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