Truthfulness and Confidentiality

5


Truthfulness and Confidentiality




Learning Objectives


After completing the chapter, the reader will be able to perform the following:


• Define truthfulness, veracity, and confidentiality.


• Identify the three variables involved in expectations of truth.


• Cite circumstances in which a person has a right to the truth.


• List and define three types of obligatory secrets.


• Explain the importance of the professional secret.


• Cite exceptions to confidentiality.


• Identify and discuss the elements of defamation, including slander and libel per se.


• Specify situations that may trigger the duty to warn third parties.


• Identify the conflict between confidentiality and disclosure of HIV and AIDS.


• List the statutory obligations regarding AIDS and HIV.


• Define the patient’s right of access to medical records.


• Identify ways that the patient’s right of access may come into conflict with the ethical and legal principles by which the imaging professional must practice.



Key Terms




Professional Profile



Ethical codes and the Health Insurance Portability and Accountability Act (HIPAA) are an important part of all health care professions. The Society of Diagnostic Medical Sonographers (SDMS) has adopted ethical codes and examination protocols specific for diagnostic ultrasound. These issues define how I as a sonographer interact with patients, family members, and colleagues. Consistent protocol guidelines help to maximize patient benefits while minimizing potential harm.


My approach to each patient is similar, whether it is an obstetrical or an arterial duplex examination. Patient privacy and dignity are forefront. Interpreters are requested when there is a language barrier. Questions regarding the patient’s medical history are discussed in private. Explaining the procedure, answering questions, and alleviating fears prior to and during the examination are routine.


Diagnostic ultrasound is dependent on the education, knowledge, and clinical skills of the operator. When pathology is encountered, I must broaden the minimum standard guidelines to achieve additional pertinent diagnostic information. Continuing to update my knowledge and skills is an important part of my ethical responsibility to both patients and colleagues.


The approach of health care professionals to medical care is defined by legal regulations and codes of conduct. These protections have been adopted in the interest of the patient to ensure fair and consistent medical care. As sonographers, we are responsible for continuing to update our knowledge and skills and treating every patient equally while respecting his or her individual rights and beliefs.




ETHICAL ISSUES


The struggle between confidentiality and truthfulness is a common one in medical imaging, as in all of medicine. Imaging professionals have to consider when they must tell the whole truth and in what situations the whole truth may compromise the patient’s outcome. On the other hand, some truths must be kept confidential. The difficulty for the imaging professional is in knowing what may be ethically concealed and what must be revealed.


The information required during the informed consent process is discussed in Chapter 4. This chapter discusses issues regarding truthfulness and confidentiality in imaging professionals’ dealings with patients, surrogates, and other health care professionals. For example, if an imaging professional overhears a physician telling a patient not to worry, the chest x-ray film looks fine, but she should have another x-ray film in 6 months, should the imaging professional indicate to the patient that she has a spot on her lung and may have a problem?



IMAGING SCENARIO


Several accident victims arrive at the emergency department, and the trauma imaging specialist assigned to perform portable x-ray examinations becomes involved in a family’s fight for life. The mother is critically injured, and a strong possibility exists that she will not survive. Her husband is making good progress. The physician tells him his wife is dying. The man then insists that his wife and children be told, but the physician decides not to tell them because it would only cause them more pain. The wife dies the next day.


The trauma imaging specialist is aware of this interaction because he is busy with chest imaging when the husband requests that his wife be told about her condition. The imaging professional knows this physician has a history of determining patients’ needs, often contrary to their wishes. During one of the imaging procedures, the man asks the imaging professional what he thinks about the physician, but the trauma imaging specialist declines to share any information with the husband.



The chapter also discusses the principles covering situations in which the truth should be kept confidential. For example, must an ultrasonographer conceal from a mother that her 13-year-old daughter is pregnant and desires an abortion?



TRUTHFULNESS AND VERACITY


Definitions


Truthfulness is defined as conformance with fact or reality. However, the perception of fact and reality may change, so truthfulness is a somewhat fluid concept. Veracity is defined as the obligation to tell the truth and not to lie or deceive others. Veracity and truthfulness have long been regarded as fundamental to the establishment of trust among individuals, and they have a special significance in medical imaging and other health care relationships. Imaging professionals and patients may have differing perceptions of veracity and truthfulness. Imaging professionals may believe in telling the whole truth, no matter how painful, but the patient’s need to know the truth may be entirely different.







Circumstances for Expectations of the Truth


Truthfulness is summed up in two commands: “Do not lie, and you must communicate with those who have a right to the truth.”1 The first command leaves the imaging professional free to not communicate to avoid telling a lie, and the second constrains the professional to share information only with those who have a right to the truth.




A lie is a falsehood told to a person who has a reasonable expectation of the truth.1 The ethics of lying is judged in terms of consequences for the individual and society. The expectation of truth varies with the following conditions:





All three of these conditions are related to the obligation of confidentiality and the right to privacy (Figure 5-1).


image
FIGURE 5-1 Components of a reasonable expectation of truth.



If an imaging student, within earshot of a patient, asks a clinical instructor about pathologic changes on an image, he or she does not have a reasonable expectation of truth. The question asked in this place of communication may force the instructor to avoid telling the truth about the examination results if the patient might overhear the conversation and become distressed. Students do have an expectation of truth, however, if they ask the same question in the classroom during a film analysis class. This is an example of expectations varying with the place of communication.


If an imaging student asks the clinical coordinator for information about another student’s performance on a clinical competency examination, the inquiring student has no reasonable expectation of truth because of the roles of the two communicators. The score of another student is not the student’s concern, and the clinical coordinator has an obligation of confidentiality to all the students.


The nature of the truth involved alters the expectation of truth in questions concerning private matters. If an imaging professional asks a student or any other person about finances, sex life, or anything of a personal or private nature, the imaging professional should not expect a truthful answer.


Overly curious imaging professionals may be found in many imaging departments, just as overly curious people are found in every profession. Such people have unreasonable expectations of the truth. The temptation is to tell these people to mind their own business, but this is not always the wisest course in the hospital setting, where teamwork is imperative. “Snoopy” imaging professionals have no reasonable expectation of the truth and should be counseled about their unprofessional behavior.


Concealment of the truth is not necessarily a lie, and in certain situations the imaging professional does not have to tell the whole truth. Thus the question arises concerning the circumstances in which people have a right to the truth.



RIGHT TO THE TRUTH


A person has the right to truthful communication during the informed consent process, when making decisions about treatment, and when making important nonmedical decisions. If a patient’s computed tomography (CT) scan reveals that lung cancer has spread to the liver and other vital organs, the patient needs to be informed of this terminal condition to make necessary plans. If the information is not provided, the patient may not make necessary arrangements or deal with family, psychological, and spiritual issues. In cases of terminal illness, such practical needs are often more important than medical needs to the patient.


In the previous section the patient’s expectation of the truth was mentioned. This is an important consideration for the imaging professional because the patient may ask about the outcome of an imaging examination, fully expecting the truth. The truth about the examination, however, may entail information only a radiologist or the patient’s physician can provide. Therefore the imaging professional in this situation cannot provide the whole truth to the patient. For example, if the patient expects a truthful answer to the question, “Has my cancer spread?”, the imaging professional must deal with the patient’s expectation of truth by being considerate and understanding but must explain to the patient that the radiologist or the patient’s physician will provide this information. Imaging professionals do not have the authority to discuss pathologic findings with patients. In this type of dilemma they have to avoid the whole truth even if they are certain that the cancer has spread. Image interpretation for the patient is the purview of the physician, who is also qualified to answer follow-up questions.



CONFIDENTIALITY


Considerations of confidentiality are as important as truthfulness in the discussion of patients’ rights and the imaging professional’s obligations. Confidentiality concerns the keeping of secrets: “A secret is knowledge a person has a right or obligation to conceal. Obligatory secrets are secrets that arise from the fact that harm will follow if a particular knowledge is revealed.…These are the natural secret, the promised secret, and the professional secret”1 (Box 5-1).



BOX 5-1   OBLIGATORY SECRETS


An obligatory secret is a confidence that will result in harm if it is revealed. Obligatory secrets are of three types:








OBLIGATORY SECRETS


Natural Secrets


Information shared in a natural secret is by its nature harmful if revealed. An imaging professional may know that a patient has acquired immunodeficiency syndrome (AIDS) but has the obligation to keep the knowledge confidential. If the information is made public, the person positive for human immunodeficiency virus (HIV) could have difficulty gaining employment and might be persecuted socially. Some situations are more complex. For example, a cardiovascular technologist is involved in a procedure that indicates a patient needs immediate cardiac surgery, but the patient decides not to have the surgery. Within a few days the technologist boards an airplane and realizes the pilot is the patient who chose not to have cardiac surgery. Should the technologist tell the airline or some other authority of the pilot’s medical condition? Does the harm that may come from concealing the natural secret outweigh the harm to the former patient?



Promised Secrets


Knowledge a person has promised to conceal is a promised secret. The harmful effects of breaking a promise complicate professional relationships and discourage the sharing of privileged information that may be vital to patient care. Imaging professionals who cannot be trusted to keep secrets about patients or co-workers not only breach confidentiality, but also lose trust as employees or friends. Proportionality must govern the imaging professional’s decisions about divulging promised secrets. If the risk of keeping the secret outweighs the harm to the patient or friend, the imaging professional must make a decision. For example, if a student technologist knows another student has hepatitis (and has sworn not to tell because graduation is in a month and the student with hepatitis has already used the maximum sick time) and they are both scheduled to scrub for an invasive vascular procedure, the student may choose to confide in an instructor if concerned about the spread of infection, regardless of the degree of risk to the patient. The student’s peace of mind is important when it may influence the successful completion of the procedure. The student who promises a classmate to keep such a secret may need to reevaluate the ethical implications of this kind of promise.



Professional Secrets


The most binding of the obligatory secrets is the professional secret. When professional secrets are revealed, both the patient and the imaging profession are harmed. This damage to the reputation of the imaging profession harms the community, which depends on a limited number of professionals for imaging services. If people lack faith in imaging professionals, they may choose not to have necessary imaging procedures performed. This in turn complicates the diagnostic process and endangers the health of patients.


The importance of professional secrecy has been recognized by society. A body of laws encourages privileged communication and the maintenance of confidentiality between health care providers and patients. The Patient’s Bill of Rights of the American Hospital Association (AHA) describes the importance of professional secrecy in the hospital setting based on the nature of the knowledge, the implied promise of secrecy, and the good of society and the profession (see p. 255).



EXCEPTIONS TO CONFIDENTIALITY


Some exceptions to confidentiality are mandated by state law. They include mechanisms for the reporting of certain types of wounds, communicable diseases, automobile accidents, abuse, birth defects, drug addiction, and industrial accidents. State requirements may vary.


The AHA’s Committee on Biomedical Ethics notes the following conditions in which confidentiality may be breached2:


Also subject to state law, confidentiality may be overridden when the life or safety of the patient is endangered such as when knowledgeable intervention can prevent threatened suicide or self-injury. In addition, the moral obligation to prevent substantial and foreseeable harm to an innocent third party usually is greater than the moral obligation to protect confidentiality.


In many jurisdictions, imaging professionals are required to report suspected cases of child and adult abuse. Such situations may involve families with whom they are familiar. The family may urge them not to intercede because the abuser is in treatment and the reporting mechanism might deter continued treatment. Although this may be a difficult situation for the technologist, employers expect loyalty to the institution, which includes the reporting of abuse.


Exceptions to confidentiality may be debated in discussions of the family’s need to know (as in the case at the beginning of this chapter), exceptions concerning children and adolescents (e.g., abortive processes, treatment for sexually transmitted diseases), medical condition of public figures (e.g., whether Americans have the right to know if the President is in critical condition), use of hospital records for research and billing purposes, and third-party payers (e.g., need for payment balanced against patient confidentiality). Exceptions to confidentiality are discussed further in the legal section of this chapter and are listed in Box 5-2.



BOX 5-2   EXCEPTIONS TO CONFIDENTIALITY





CONFIDENTIALITY AND AIDS


Imaging professionals are not usually placed in situations in which they must inform a patient that they have HIV. Occasionally, however, patients ask imaging professionals if they are HIV positive. Imaging professionals must decide based on institutional rules and professional experience whether this information is necessary for the patient to give informed consent. Other situations may be just as difficult. An imaging professional may need to report a fellow technologist who has AIDS and does not take necessary protective measures with patients. Although the revelation may cause grief and loss of social contacts or even employment, the technologist must consider the good of patients and the profession.


Some professionals are deontologists and believe that stricter rules of right and wrong should be used in keeping information confidential. They believe that the act of keeping information confidential is more morally important than the consequences this act may cause.


Because of these differing and often conflicting viewpoints, questions concerning AIDS will continue to fuel public debate. The hope, however, is that a cure or vaccine will be discovered and the problem will no longer haunt the public and health care professionals.


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Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Truthfulness and Confidentiality

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