Running head: BRIDGE TO ETHICS PAPER: PATIENT CONFIDENTIALITY 1

Bridge to Ethics Paper: Patient Confidentiality

Hannah Braley

James Madison University

Introduction

According to Institute of Medicine (U.S.) Committee on Health Research and Privacy of Health

Information, the term “privacy” is used in healthcare to denote the concepts of confidentiality and

security as related to personal information that is gathered, stored, and released” (Nass, 2009).

Maintaining patient confidentiality and establishing trust is a very important aspect of the healthcare

profession that can be imperative to the quality of care that is provided to a patient. Nurses in specific

play a role in the process of patient confidentiality through direct interactions with patients,

documentation of events, and releasing of patient information to respective personnel. When this process

is undermined or disregarded by healthcare professionals, it can cause a strain on the provider/patient

relationship as well as cause serious legal repercussions due to the laws mandating patient confidentiality.

The Healthcare Insurance Portability and Accountability Act of 1996 addresses patient’s rights to

privacy and confidentiality regarding healthcare (HHS Office, 2017). HIPPA provides standards that

protect medical records and personal health information of patients (HHS Office of the Secretary, 2015).

This act helped create a standard of care for patients and allowed for trust to be established within

relationships between healthcare providers and patients. However, in 1974, due to a legal situation that

reached the Supreme Court (Tarasoff vs. Regents), a new law was enacted named “The Duty to Warn and

Protect.” This law states that healthcare professionals now have a legal obligation to breach the

confidentiality of their patients and warn a third party if direct threats are made by the patient (Hanson

and Garcia, 2015). With these different privacy laws in mind, it is important to understand how impactful

their implementation can be when providing care to a patient.

Background

While at a clinical site, I had an encounter with a care team that was experiencing an ethical

dilemma. The patient was in college and was recently hospitalized for suicidal thoughts and ideations

related to depression. The patient was released from the hospital under the condition of attending an

outpatient program to deal with the depressive state and ideas.

During the group therapy session in the outpatient facility, the doctor asked each of the patients

to rate their current state on a scale of 1-5 (1 being very unstable, and 5 being very stable). This patient

reported feeling like a 1 on the scale. The doctor asked the patient to describe why they were feeling this

way. The patient stated they could not talk about how they were feeling because they were afraid stating,

“If I tell you how I’m feeling, you will just send me back to the hospital, and I can’t go back to the

hospital.” The doctor responded saying, “I promise we won’t send you back to the hospital if you tell me

what you are feeling.” After receiving this reassurance from the doctor, the patient expressed their intense

thoughts of suicide and explained the suicide plan that they wanted to carry out when getting home later.

They patient also stated that this was the most suicidal they had ever been. After the group therapy session

had ended, the doctor called the care team together to discuss the proper course of action for the patient.

The doctor felt very badly that he had made a promise to the patient that he did not think he would be able

to keep, because the patient’s safety was now in jeopardy. The care team discussed different alternatives

to hospitalization, such as reaching out to the parents and allowing them to make the decision, or keeping

a close eye on the patient for the next few days.

Many different emotions and considerations were discussed throughout this decision-making

process. The care team did not want to lose the trust of the patient by re-admitting them to the hospital

against their will, however, they ultimately knew that it was the best decision for the patient’s safety. The

care team expired all options, contacted the parents, and after talking individually to the patient, they

decided that re-hospitalization was the necessary action to take, and the parents had to involuntarily take

the patient back to the hospital.

My initial response to this situation was one of empathy. I felt very sad for this individual and

what they were going through. I felt that any alternative to hospitalization would be ideal, because it went

against the patient’s wishes, took away some rights of the patient, and would likely cause an untrusting,

and anger-provoking response from the patient. However, an alternative response to the situation would

have been one very objective in nature. Knowing that the safety of the patient was in jeopardy, I could

have responded in favor of hospitalization to keep the patient safe. This situation caused me moral

distress because it was clear to the whole care team what the right thing to do in the situation was. This

was also clearly a dilemma, however, I feel that moral distress applies more to the situation because the

right decision was evident, though hard to come to terms with. The most important outcome of the

situation is to keep the patient safe, however, going against the patient’s wishes potentially losing the trust

of the patient is a hard aspect to overcome.

Methods/Findings

When making decisions in which ethics are heavily involved and influential, it is important to

make many considerations and even apply a method or system to the thought process which may help to

determine the best action to take in the given situation. These systems can also help a person feel more

comfortable and justified by the decision made in an ethical dilemma. An example of one of these

systems is the Eight Key Questions. These are a set of guidelines that were established by the institution

to help establish ethical standards to guide decisions. (“The Eight Key Questions,” n.d.). These guidelines

are reflective of the best outcomes and act as a framework for decision making skills. In this situation, the

eight key questions can be applied to reflect the ethical decision making process and the possible

outcomes of each aspect of the process.

Fairness is a difficult ethical consideration in this situation because acting equitably and

balancing interests is hard to do when emotions are involved. In addition, fairness may be different to the

patient than the providers. In this circumstance, acting fairly in the eyes of the patient was very different

than acting fairly in the eyes of the care team and other authorities. The patient felt that the decision to

hospitalize them was unfair, but the care team involved had to consider and balance the interests such as
BRIDGE TO ETHICS PAPER: PATIENT CONFIDENTIALITY 5

safety, the patient’s wishes, and the legality of the situation. When exploring the outcomes of the

situation, it is clear the best short term outcome is to keep the patient safe and the ideal long term outcome

is to improve the patient’s condition and keep them free of self-harm and any thoughts of self-harm.

Knowing and identifying these as the best outcomes helps to guide the decision making and to lead the

patient toward these successful outcomes. When it comes to the responsibilities of those involved, it is the

duty of doctor and the nurses is to keep the patient safe and to act in a way to promote the health of the

patient and do no harm. According to the “Duty to Warn and Protect,” it is stated that it is the

responsibility of the healthcare team to report the incident because they are aware that the patient is

threatening self-harm (Hanson and Garcia, 2015). After considering these responsibilities of healthcare

professionals and knowing the ideal outcomes, the right ethical decision becomes more clear and evident.

Character is also an important aspect of upholding the level of respect and duty of healthcare

professionals. The care team in this case did not want the patient to feel as though they had poor character

by lying to the patient, however, knowing that a safe, ethical decision was more of a priority.

Liberty is a very important aspect of this situation because the decision made was going to

directly affect the patient’s freedom, consent, and autonomy. Having the patient committed involuntarily

clearly defies consent, and jeopardizes their autonomy. Although healthcare professionals make it a goal

to provide patients with these aspects of liberty, in this situation liberty is a secondary concern to the

safety of the patient. Empathy is another important ethical consideration in this situation because

empathizing can easily interfere with the decision-making process, potentially causing harm to the

patient’s overall health and safety. While it is important to have an empathetic outlook and to incorporate

empathy into patient cares, allowing these emotions to get in the way poses a threat to the patient’s safety,

thereby becoming less of a concern at the time. Authorities are an important consideration in this

situation. Authorities (law, doctors, etc.), expect the healthcare team to act in a way that creates the best

outcome for the patient, while also protecting their health and safety. This also includes the legal

authorities and responsibilities of the healthcare team, which emphasizes the safety of the patient. Lastly,

rights apply similarly to liberty in this situation, because a person has the right to make their own
BRIDGE TO ETHICS PAPER: PATIENT CONFIDENTIALITY 6

decisions, to refuse treatment, etc., however, the question is if there are or should be any limitations to

these rights.

The third provision of the American Nurses Association’s Code of Ethics (2015) states that, “the

nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” This

provision of the Code of Ethics applies heavily to this ethical situation because it demonstrates the

importance of the nurses’ role in protecting the health and safety of the patient before any other aspects

such as compassion and empathy can become involved in care. This is true because if the patient is unsafe

or unhealthy, the role of the nurse and the healthcare team would be obsolete.

Conclusion

Encountering and ethical dilemma like this is a very impactful experience. The learning

experience created many opportunities to use critical thinking skills, ethical reasoning skills, and apply

different systems of evaluation to help form a decision guided toward the best interest of the patient. In

addition, this situation provided a learning experience regarding patient confidentiality and all that it

entails. It became very clear to me that ethical encounters are very common in the nursing field, and that

standards of confidentiality, patient rights, and privacy can all be impacted when important issues such as

safety come into play during care. Looking back on the situation, making a promise to the patient about

their care was not an effective way to deal with their needs. Making promises can provide false hope for

patients and this can impact the type of care that is expected by the patient, and the type of care that is

provided by the healthcare team. But since I was not in control of making this promise to the patient, I

personally would have liked to find the courage to input my opinion and implement tools such as the

Eight Key Questions to the decision-making process. In addition, I would have also taken a more

objective stance on the situation. While I was not the one in charge of the decision to be made, I used this

experience to think about my future practice and how my emotions have the ability to impact care. I

believe that an objective opinion was necessary to provide the best patient care in this instance. Ethical

dilemmas and situations are faced by healthcare professionals around the world on a daily basis, and are

an important aspect of patient care within the healthcare setting.

References

American Nurses Association. (2015). Code of Ethics for Nurses. Retrieved March 25, 2018,

from http://www.nursingworld.org/codeofethics

Hanson, K., & Garcia, A. (2015, September 28). Mental Health Professionals' Duty to Warn.

Retrieved March 20, 2018, from http://www.ncsl.org/research/health/mental-health-

professionals-duty-to-warn.aspx

HHS Office. (2017, May 03). The Privacy Act. Retrieved March 20, 2018, from

https://www.hhs.gov/foia/privacy/index.html

HHS Office of the Secretary, Office for Civil Rights, & OCR. (2015, April 16). Privacy.

Retrieved March 20, 2018, from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

Nass, S. J. (1970, January 01). The Value and Importance of Health Information Privacy.

Retrieved March 20, 2018, from https://www.ncbi.nlm.nih.gov/books/NBK9579/

The Eight Key Questions (8KQ). (n.d.). Retrieved March 20, 2018, from

https://www.jmu.edu/mc/8-key-questions.shtml