Confidentiality is one of the core duties underscoring medical practice. It requires health care providers to keep a patient’s personal health information private unless consent forms are signed by the patient. Patients routinely share personal information with health care providers but a breach of confidentiality occurs when a patient’s private information is disclosed to a third party without his or her consent. There are limited exceptions to this: disclosures to state health officials and court orders requiring medical records to be produced. Situations in which confidentiality will need to be broken include evidence of physical, sexual or serious emotional abuse or neglect; threatened or attempted suicide; evidence of serious self-harm (including drug or alcohol abuse) that may be life-threatening.
An article in NEJM (New England Journal of Medicine) a few years ago argued that medical confidentiality, as it has been traditionally understood by patients and doctors, no longer exists. This ancient medical principle, which has been included in every physician’s oath and code of ethics since Hippocratic times, has become old, worn-out, and useless; it is a decrepit concept. Efforts to preserve it appear doomed to failure and often give rise to more problems than solutions.
But in recent weeks, debate has raged within the profession about whether, if experts believe US president Donald Trump is mentally ill, they have a duty to inform the public. Many who choose to speak out contend that he has the traits of a sociopath. A group comprising 35 psychiatrists and social workers recently wrote a letter to New York Times warning that Trump is dangerous and one psychologist John Gartner has launched a petition entitled “Mental health professionals declare that Trump is ill and must be removed.”
Two rules govern US healthcare professionals and patient confidentiality, 1) The Goldwater rule was issued by the American Psychiatric Association in 1973 after it surveyed its members about Senator Barry Goldwater, then Republican nominee for president. Nearly half of the responding psychiatrists said he was mentally ill, and some described him as “paranoid” and “grossly psychotic.” Goldwater successfully sued “Fact”, the now defunct magazine that published the results of the survey, for libel. The American Psychological Association’s code of ethics states that psychologists “should not offer a diagnosis in the media of a living public figure they have not examined.” 2) The Tarasoff rule established that healthcare professionals have a “duty to warn” if they believe a patient in their care may be a threat to others. This rule grew out of a civil suit filed by the relatives of Tatiana Tarasoff, a student at the University of California who was stabbed to death by Prosenjit Poddar, a fellow student who had been stalking her. Tarasoff’s family successfully sued the therapist for failing to warn them after Poddar had confided he was planning to kill her. Since the Tarasoff ruling, depending on the state in the US, health professionals are required by law to warn people (and/or law enforcement) if a patient makes serious threats of harm against them.
Although patient confidentiality has been a fundamental ethical principle since the Hippocratic Oath, it is under increasing threat. The main area of confidentiality becomes how to manage patients’ records. Physicians must be able to store and dispose of medical records securely. Patients should be asked whether some information should be kept out of the record or withheld if information is released. Patient identity must be kept secret during peer review of medical records. Electronic technology and communications are potential major sources of breaches of confidentiality. Computer records must be carefully protected from casual browsing or from unauthorized access. Fax machines and cordless and cellular telephones can allow unauthorized people to see or overhear confidential information. Conversations among hospital personnel in elevators or public cafeterias can result in breaches of confidentiality. Patient confidentiality is a right that must be safeguarded by all health care personnel.
Even if some professionals ask, “Is Donald Trump a sociopath? or “Is Narendra Modi a psychopath?” the question is not whether these personalities are “extreme.” Rather, it is whether they are disturbed in a psychological sense and, if so, whether their possible personality disorders could lead to disastrous consequences since they have accumulated vast powers in their hands.
Hitler was labeled a psychopath but Ian Kershaw, a Hitler biographer, says, “We well know that he could be kind and considerate to his secretaries, and with the next breath show cold ruthlessness, dispassionate brutality, in determining the deaths of millions.” History depicts Hitler as crazed but maybe he wasn’t. Heinous crimes are committed all the time by perfectly sane people, real, three-dimensional people. We reflexively caricaturize these people and it makes us uncomfortable when our caricatures are challenged. So was Hitler really crazy, or is that just a common misconception?
Let’s see if we get some answers from our local psychoanalyst-luminaries Dr. Sudhir Kakar and Dr. Vikram Patel who have made Goa their home. Paging Dr. Kakar and Dr. Patel for their learned opinions!
(Dr. Francisco Colaço is a seniormost consulting physician, pioneer of Echocardiography in Goa.)
