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Maintaining confidentiality
8984
Maintaining confidentiality Matters medical have polarised US senators in recent months, but the issue of keeping patients’ medical records confidential brought a group of them together last week (see p 1217). The Hippocratic Oath is unequivocal on the duty of doctors to keep secret personal information gained in the course of their practice. The breadth of this obligation has been reduced over time; exceptions now chiefly concern breaches of the law, medical evidence in court cases, and endangerment of the public. But the underlying principle has been maintained: patients have the right to expect that the information doctors gather in a professional capacity will not be divulged. However, practical difficulties outside the profession’s control have often hindered attempts to ensure absolute confidentiality. In 1961, Michael Balint described the problem in this journal: "Though every hospital has screens to protect the patient against loss of privacy by sight, there are very few hospitals indeed-anywhere in the worldwhere a doctor may talk to his patient safe in the knowledge that their confidential conversation will not be overheard". Thirty-four years later, it is unlikely that standards in hospitals have improved uniformly. In addition, the growth in the use of information technology has increased the likelihood of sensitive information being "overheard" or, worse
still, actively sought. Heavy reliance on electronic communication systems is at the heart of plans for health-service reforms throughout the world. For instance, the electronic medical record is touted as a means to cut costs and improve quality of care. Data on longterm clinical outcomes or adverse drug reactions can be stored, and the implementation of practice guidelines can be monitored. Opportunities for using information currently available only in patient notes are legion. Natural language processing is one example of a technique designed to extract clinically important information from complex narrative reports such as patient histories. But use of electronic technology within medicine has already led to unacceptable breaches of confidentiality. Patients’ details have been sent from hospital to
November 4, 1995
hospital by fax, and poor security in some computerised record systems has allowed third parties with no right of access to "browse" at will. The benefits of electronic data storage and retrieval are undeniable, but a database should be less vulnerable than a filing cabinet, not more. Against this background, it is not surprising that several countries other than the USA are developing privacy commissions and codes of healthinformation confidentiality. It is, however, surprising that at least two countries should be contemplating a relaxation of a doctor’s obligation to maintain silence. The Australian Medical Association, during the past few weeks, has decided not to press ahead with its proposed plans to allow doctors to breach confidentiality if patients refuse to tell their sexual partners that they are infected with HIV or have AIDS. Meanwhile, the British medical profession’s guiding body, the General Medical Council, has produced updated guidelines on the duties of a doctor, which state that where a patient who is HIV positive or has AIDS has withheld consent "the doctor may consider it a duty to seek to ensure that any sexual partner is informed, in order to safeguard such persons from infection". Such guidance invites doctors to ignore the express wishes of a patient regarding confidential information. If such a recommendation is put into practice, it will create an atmosphere of poisonous mistrust between doctor and patient. The likely harmful effects are clear. In the setting of flexible rules on confidentiality, patients will be wary of telling their doctors the truth. Balancing two sets of rights-A’s to confidentiality, B’s to safety-will always seem difficult. In truth, we believe the issue to be unambiguously clear. Doctors must remain responsible to their patients before all else. Once physicians become instruments of social control or prey to societal factions-no matter how well
intended-they
consulting-room collaborators, threatening rather than preserving their patients’ trust. act
as
The Lancet
1173
Maintaining confidentiality Matters medical have polarised US senators in recent months, but the issue of keeping patients’ medical records confidential brought a group of them together last week (see p 1217). The Hippocratic Oath is unequivocal on the duty of doctors to keep secret personal information gained in the course of their practice. The breadth of this obligation has been reduced over time; exceptions now chiefly concern breaches of the law, medical evidence in court cases, and endangerment of the public. But the underlying principle has been maintained: patients have the right to expect that the information doctors gather in a professional capacity will not be divulged. However, practical difficulties outside the profession’s control have often hindered attempts to ensure absolute confidentiality. In 1961, Michael Balint described the problem in this journal: "Though every hospital has screens to protect the patient against loss of privacy by sight, there are very few hospitals indeed-anywhere in the worldwhere a doctor may talk to his patient safe in the knowledge that their confidential conversation will not be overheard". Thirty-four years later, it is unlikely that standards in hospitals have improved uniformly. In addition, the growth in the use of information technology has increased the likelihood of sensitive information being "overheard" or, worse
still, actively sought. Heavy reliance on electronic communication systems is at the heart of plans for health-service reforms throughout the world. For instance, the electronic medical record is touted as a means to cut costs and improve quality of care. Data on longterm clinical outcomes or adverse drug reactions can be stored, and the implementation of practice guidelines can be monitored. Opportunities for using information currently available only in patient notes are legion. Natural language processing is one example of a technique designed to extract clinically important information from complex narrative reports such as patient histories. But use of electronic technology within medicine has already led to unacceptable breaches of confidentiality. Patients’ details have been sent from hospital to
November 4, 1995
hospital by fax, and poor security in some computerised record systems has allowed third parties with no right of access to "browse" at will. The benefits of electronic data storage and retrieval are undeniable, but a database should be less vulnerable than a filing cabinet, not more. Against this background, it is not surprising that several countries other than the USA are developing privacy commissions and codes of healthinformation confidentiality. It is, however, surprising that at least two countries should be contemplating a relaxation of a doctor’s obligation to maintain silence. The Australian Medical Association, during the past few weeks, has decided not to press ahead with its proposed plans to allow doctors to breach confidentiality if patients refuse to tell their sexual partners that they are infected with HIV or have AIDS. Meanwhile, the British medical profession’s guiding body, the General Medical Council, has produced updated guidelines on the duties of a doctor, which state that where a patient who is HIV positive or has AIDS has withheld consent "the doctor may consider it a duty to seek to ensure that any sexual partner is informed, in order to safeguard such persons from infection". Such guidance invites doctors to ignore the express wishes of a patient regarding confidential information. If such a recommendation is put into practice, it will create an atmosphere of poisonous mistrust between doctor and patient. The likely harmful effects are clear. In the setting of flexible rules on confidentiality, patients will be wary of telling their doctors the truth. Balancing two sets of rights-A’s to confidentiality, B’s to safety-will always seem difficult. In truth, we believe the issue to be unambiguously clear. Doctors must remain responsible to their patients before all else. Once physicians become instruments of social control or prey to societal factions-no matter how well
intended-they
consulting-room collaborators, threatening rather than preserving their patients’ trust. act
as
The Lancet
1173