The Importance of Confidentiality in Healthcare
Confidentiality refers to the prevention of inappropriate disclosure of patient information and ensuring that patient data is safely recorded and maintained. Every patient is entitled to have the right to confidentiality of their medical information. Health care service providers have an ethical and legal responsibility to protect healthcare information like patient details, medical records, intervention plan, evaluation of intervention plan, etc. by not sharing the information with a third party unless consented by the patient. A health professional might face an ethical and legal dilemma while taking consent to essential disclosure of information from children, older adults, and individuals with impaired decision-making abilities. In such a context, the patient can exercise the right to power of attorney. The concerned patient can designate the legal authority to consent to the disclosure of information to a close family member or relatives who are competent enough to consent to the confidentiality breach (Appel, 2019).
In healthcare settings, autonomy refers to the competence of a patient to make informed medical decisions related to one’s health and wellbeing. Every patient has the right to freedom of autonomy and choice in the healthcare setting. Patients have the right to provide informed consent to or refuse life-sustaining treatment, notwithstanding the fact that the informed decision might seem insensible, irrational, and non-existent to the healthcare professionals and others Holten Møller et al. 2019).
Paternalism in healthcare settings refers to the belief that any group or person is not capable of making the best medical choices for themselves. It entails interfering with the autonomy or liberty of another person, with an intention of promotion of good or prevention of harm to that particular person (Walsh et al. 2017). Paternalism can lead to patient dissatisfaction, negative healthcare outcomes, breach of patient rights, and interference to self-determination of the patient. Due to paternalistic ideologies in the healthcare professionals, the patients might disengage from the development of the intervention plan and the patient's right to freedom of choice will be threatened (Lepping et al. 2016).
The safety of the patient is an important aspect of any healthcare system. Risk assessment, risk monitoring, risk analyzing, risk evaluation, and reduction of risk are mandatory steps in risk management (McCradden et al. 2010). In mental health settings, risk management can often interfere with the safety of the patients. For instance, in patients with dementia, independent movement can lead to unprecedented risks. Therefore, the patient might require to be assisted by a caregiver during movements. Another feature of the risk management plan is to not interfere with the patient independence, allow reasonable risk yet reduce the possibility of harm.
In mental health settings, nursing professionals are also at a higher risk of physical harm, harassment, molestation, accusations, and verbal abuse. To reduce such risks, the nursing members have to be trained in the application of non-restrictive de-escalating measures, use of communication, and interpersonal skills to address the grievances of the patients.
Every healthcare practitioner is bound to the moral duty to promote a course of action in the medical setup in the best interest of the patient. Beneficence refers to engaging in activities that contribute to the welfare of the patient. Beneficence refers to balancing the benefit of treatment against loss and risk involved, on the other hand, non-maleficence refers to avoiding harm (Have and Neves 2021).
The Significance of Autonomy in Healthcare Settings
Non-maleficence refers to the course of actions taken by the medical practitioners to avoid intentional harm or take appropriate steps to minimize harm. Beneficence is encouraged activities that will benefit the patient. All Patients must be supported by caseworkers/ nurses as they can heal and provide care. This shall apply to all the aspects of care, including the administration of medications and the provision of education and information to patients (Ong-Flaherty et al. 2016). The patient’s risk assessment should be carried out at frequent intervals, the assessment should be analyzed and evaluated.
An ethical dilemma in a clinical setting occurs when a professional is faced with two conflicting moral requirements, which require the professionals to compromise their ethical standards. In the following section, the ethical dilemmas in the case of Holly and Joran will be analyzed from the professionals’ point of view.
One of the ethical standards of conduct, performance, and ethics for nurses and midwives as outlined by the Nursing and Midwife Council (NMC, 2008), to preserve the autonomy of a healthcare consumer, the nurse should ensure to gain informed consent before beginning any duty of care. This code of conduct outlines the ethical considerations of respect and support of health consumers’ rights to accept or decline care. The NMC additionally states that nurses should fully involve the healthcare consumers in making decisions about their care plan. However, the NMC also outlines the mental competence of the consumer should be determined before a care plan decision is taken. If a consumer does not have the mental capacity to consent to one’s care plan, the needs and autonomy of the consumer should be prioritized and safeguarded at all costs.
Holly is a 45-year-old woman with severe learning difficulties and cannot communicate verbally without the support of Makaton. Jackie is the care worker of Holly and Jackie cut off Holly’s long fingernails as a part of personal care as she believed that Holly might hurt herself with the same. Jackie’s manager initiated a disciplinary procedure against her for three reasons: for violating Holly’s autonomy, not taking informed consent from Holly before beginning the care procedure, and not taking a collaborative decision with the other care team members. However, from the perspective of Jackie, she had taken the decision to cut Holly’s fingernails as a part of personal care and in seemingly the best interest of Holly (so that Holly does not scratch herself). It is to be understood that Holly had clearly protested against Jackie’s decision in the beginning but succumbed to her decision at the end.
On analysis, it can be noted that Jackie had displayed a rather paternalistic attitude towards Holly. This has resulted in the restriction of her freedom to express her autonomy and choice. Similarly, Jackie might have considered Holly incapable or incompetent to provide consent to her care plan as she has difficulty verbally expressing herself. Therefore, Jackie might have based her decision on two major understanding: Holly is incompetent to provide informed consent and that she is in a superior position to take a decision in the best interest of Holly. This understanding of Jackie is, however, very skewed, against the ethical standards of the nurses, and led to the violation of patient rights (right to autonomy, right to choose, and right to informed consent). Therefore, the ethical dilemma, in this case, arose from the contrast between the personal beliefs and the ethical standards outlined for the healthcare professionals.
Paternalism in Healthcare: Implications for Patient Rights
It is essential for nurses to recognize one’s belief system, nursing worldview, and biases so that they can take ethically sensitive decisions for the care of the consumers. In this case, Jackie had failed to identify her underlying personal biases in the nursing decisions she made.
According to the ethical standards of practice and code of conduct outlined by NMC (2008), every nurse should respect the healthcare consumer’s right to confidentiality. Additionally, the code of conduct highlights that if the personal information related to the patient is to be shared with a third party for collective benefits, the patient should be informed about the same. Consent should be elicited from the particular patient before the confidential information related to the patient is disclosed to the family members or other members of the care team. In this context, the breach of confidentiality is legally sanctioned if the disclosure of information can reduce the risk of someone being at risk of harm in line with the law of the country where the clinical practice is taking place.
In Jordan’s case, the ethical dilemma had arisen from the contrasting ethical responsibility to preserve the confidentiality of Jordan’s diagnosis, yet ensure safety for his wife and reduce the harm that can be caused if the syphilis diagnosis is concealed from his wife. Therefore, the ethical issue of preserving the confidentiality of a patient and ensuring non-maleficence and beneficence for other patients (Bufacchi 2020). If Jordan’s wife is treated for a possible syphilis infection (possibly infected by Jordan) without the disclosure of her diagnosis, it will also lead to the violation of the patient’s right to autonomy and ethical responsibility to informed consent before a treatment procedure begins. However, the healthcare professional might be in an ethical dilemma due to them having to protect Jordan’s wife by informing her of Jordan’s Syphilis infection on one hand and other hands protect Jordan’s marriage by not informing his wife that he is bisexual and had been involved in casual sex with other men outside the marriage.
Even though the situation seems tricky enough, as the code of conduct for nurses outlined by the NMC states, the nurse must inform Jordan’s wife about the Syphilis infection and remove the risk of her getting infected and remaining untreated. If this ethically sound decision is taken by the doctor, then the issue of informed consent related to the treatment of Jordan’s wife can be handled as she will be revealed the diagnosis, and her consent will be taken before the treatment procedure begins.
This decision will preserve the ethical standards of the healthcare professionals and is also in alignment with the legislation of the country. The final ethical decision should be one that preserves the patient’s right to autonomy, informed consent, non-maleficence, and beneficence. In the above case if the healthcare professional does not inform Jordan’s wife about Jordan’s infection then it might lead to the commitment of intentional harm to the patient party (Pipien 2018). The decision will be taken for the collective benefit of the consumer and not for the personal benefit of one.
Therefore, from the above discussion, it can be concluded that exploring and understanding ethical problems is essential for patient safety and preservation of their rights. As seen in the case of Holly and Jordan, ethical dilemmas in preserving patient autonomy and confidentiality may arise in clinical settings. In the case of Holly, her right to autonomy and consent had been violated by the care worker’s paternalistic attitude. On the other than, in the case of Jordan, the ethical dilemma arose due to having to either preserve the confidentiality of Jordan’s infection or preserve the ethical responsibility of non-maleficence in care duty (Motloba 2019). The Decision-making process is a collaborative initiative of the patient party and the healthcare professionals. Therefore, healthcare professionals should analyze the dilemma using appropriate ethical frameworks and take relevant decisions.
Appel, J.M., 2019. Trends in confidentiality and disclosure. Focus, 17(4), pp.360-364.
Baron, J., 2017. Uncertainty and probability within utilitarian theory. Diametros, (53), pp.6-25.
Bufacchi, V., 2020. Justice as Non-maleficence. Theoria, 67(162), pp.1-27.
Holten Møller, N.L., Fitzpatrick, G. and Le Dantec, C.A., 2019. Assembling the Case: Citizens' Strategies for Exercising Authority and Personal Autonomy in Social Welfare. Proceedings of the ACM on Human-Computer Interaction, 3(GROUP), pp.1-21.
Lepping, P., Palmstierna, T. and Raveesh, B.N., 2016. Paternalism v. autonomy–are we barking up the wrong tree?. The British Journal of Psychiatry, 209(2), pp.95-96.
McCradden, M.D., Joshi, S., Anderson, J.A., Mazwi, M., Goldenberg, A. and Zlotnik Shaul, R., 2020. Patient safety and quality improvement: Ethical principles for a regulatory approach to bias in healthcare machine learning. Journal of the American Medical Informatics Association, 27(12), pp.2024-2027.
Motloba, P.D., 2019. Non-maleficence-a disremembered moral obligation. South African Dental Journal, 74(1), pp.40-42.
Nursing and Midwifery Council. 2008. The Code: Standards of Conduct, performance and ethics for nurses and midwives. [online] Available at: <https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf> [Accessed 12 January 2022].
Ong-Flaherty DNP, C., Banks PhD, A., Doyle MSN, M. and Sharifi, C.O., 2016. The meaning of evidence and nonmaleficence: cases from nursing. Online Journal of Health Ethics, 12(2), p.2.
Pipien, I., 2018. Beneficence and nonmaleficence in care. Soins; la revue de reference infirmiere, 63(824), pp.51-54.
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