The Ethical Dilemma of Confidentiality

Abstract

Ethical Dimensions in Health Professions along with other related peer-reviewed articles thoroughly describe how to apply ethical principles, decision-making step-by-step, and clinical reasoning. A common ethical dilemma in health care involves confidentiality. Research shows that confidentiality is often breached amongst all healthcare members. If this information gets into the wrong hands, it can damage the patients’ reputation and cause extreme humiliation. Often times ethical principals are violated when there is a dilemma. Nonmaleficence and fidelity are both violated when there is a breach of confidentiality. Minimally patients deserve to be respected. Protecting and keeping their information private is a way to show respect.

The Hippocratic Oath

“And whatsoever I shall see or hear in the course of my profession, as well as outside my profession...if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.” (

This oath refers to confidentiality; one of the most basic principles in health care practice. Confidentiality is the practice of keeping harmful, shameful, or embarrassing patient information within proper bounds, the right to privacy gives legal standing to this ethical principle.

Medicine today is practiced by healthcare teams formed not only by physicians, residents, and nursing staff, but also by nursing assistants, orderlies, administrative personnel, and even students. Many people access patients’ charts routinely as a part of their jobs to obtain pertinent information to properly treat and care for them (Beltran-Aroca, Girela-Lopez, Collazo-Chao, Montero-Pérez-Barquero & Muñoz-Villanueva, 2016). This makes it increasingly important to protect patients’ confidentiality. The duty to ensure discretion and confidentiality in the medical profession is morally justified based on the rights arising from relationships, and medical practice involves trust relationships with both patients and society.

Confidentiality can be breached without realizing it, so it is important to watch what is said, where it is said, and to whom. On a daily basis, I hear chatter amongst medical staff about other patients’ conditions and behaviors. A lot of the conversations are in places that can be overheard by other patients, staff, and visitors. It boils down to carelessness, indiscretion, and sometimes even malice. Because this is so common, who do you call out or report? What can be done on a grand scale? I cannot imagine speaking to the head attending doctor about breaching a patient’s confidentiality. Nurses must be confident enough to speak up no matter the situation or status of the professional they are addressing because we are the patient’s advocates.

My Dilemma

An ethical dilemma occurs when a moral agent is faced with two or more conflicting courses of action but only one can be chosen as the agent who attempts to bring about an outcome consistent with the professional goal of a caring response. An ethical dilemma that occurred on my unit involved a breach of confidentiality that led to discrimination and refusal to care for a patient. A nurse was giving report to another nurse on a patient who was positive for HIV. Report took place at the nurses’ station where most staff and sometimes families migrate. Anyone within 10 feet away could hear. One of the personal care assistants (PCA) overheard the report and began their own opinionated side conversation about this patient. For a chunk of the shift, this patient was singled out. Whenever someone would enter the patient’s room to help with repositioning or transporting the patient; the PCAs would warn them about the patient’s HIV status. This information was not necessary to be revealed to others. There are two general exceptions where it is necessary to question whether to maintain confidentiality: when the safety of others or public health is threatened. HIV is not contagious; so, the safety of the staff assisting this patient is not threatened. Using appropriate PPE for blood draws and peri care is standard.

Ethical Principles

Some health information is subjective impressions about the patient and their lifestyle choices and habits. Improper disclosure of highly sensitive information could damage a patients’ reputation or result in loss of opportunities. In this case, the principle that was violated is nonmaleficence; to avoid causing harm to the patient. Constantly exposing the patient’s medical history to staff who were not involved in the patient’s care could lead to personal humiliation and embarrassment. Fidelity was also violated. Fidelity is being faithful to one’s commitments to the patient and meeting their reasonable expectations. Patients minimally deserve to be respected and to keep their personal information private. The PCA also refused to draw blood on this patient. It is unethical for the PCA to refuse to assist a patient because of their health status.

There are no special precautionary measures that need to be followed when treating a patient with HIV because it is transmitted via bodily fluids. Only standard precautions need to be used; no different than most patients. I would address the first step of the decision-making process by gathering as much information as possible. The PCA’s actions were very discriminatory. Because of the stigma associated with this disease, I would assess her knowledge of the disease. What is HIV? How is it spread? What are their feelings about the disease? Would they treat the patient any different if it was a family member? How much do they know about this patient? Do they understand standard precautions and what PPE is required to draw blood for an HIV patient?

This brings me to Step 2 of the decision-making process; identifying the type of ethical problem. This situation caused moral distress. Other staff simply ignored the inappropriate behavior to avoid conflict with this senior staff worker. I knew I had to be the patient’s voice no matter what.

In step 3, the ethics approach that addressed the dilemma the best is deontology; which focuses on duty. Everyone who witnessed this behavior was moral agents that did not act on behalf of the patient. As a moral agent, it was my duty to protect this patient from humiliation.

Step 4 is exploring practical alternatives. I debated with myself if I should talk to the PCA first, contact the ethics committee, go directly to my manager, or do nothing at all. The ethics committee would entail involving more people that could cause further embarrassment and humiliation to the patient especially since she was not aware of any of it. Doing nothing would not benefit anyone going forward.

Step 5 is completing the action. I decided to talk with her first to gauge her understanding of the situation. I explained to the PCA why her actions and refusal to do her job is unethical. I also gave her the opportunity to reflect on her decision in hopes she would ultimately reconsider and do the right thing. She would not budge. I completed the blood draw myself. Although with hesitance, I reported this PCA to my manager. My manager, also a moral agent, was very upset by what she heard. She sent out a nonspecific email about HIPAA policies along with a reiteration of bedside report for confidentiality reasons. Step 6 is evaluating the process and outcome.

 Unfortunately, during the meeting, the PCA did not own up to anything; giving an unrelated excuse of why she did not draw the patient’s blood. My goal was not for her to be punished but to be made aware of her actions and how they could affect patient-staff relationships. The awareness of her actions led to a discussion amongst the other PCAs and nurses on the unit. The potential for repercussion changed how report was delivered and how patients were cared for. Nurses are now more discreet or give report at the bedside so that other people cannot overhear private information. All other staff is likely to treat all patients the same since their diagnosis is unknown. If I had not reported her, many others would think their job duties were optional and believe it is okay to violate HIPAA and discriminate against others. As medical professionals, we have a higher moral standard to uphold.

Clinical Reasoning

Narrative reasoning applies to my ethical dilemma. It is a framework for understanding the patient’s “life story” or illness experience. After building a rapport, I would try to understand the patient’s perception and feelings surrounding her diagnosis and all things leading up to it. If this is not a comfortable topic, I would focus on her background and culture and how these things may have contributed to any illnesses she has.

Ethical reasoning applies to my ethical dilemma as well. It is a mode of reasoning used to recognize, analyze, and clarify ethical problems that arise. The focus is not on what could be done for the patient, rather on what should be done. I struggled with deciding what the right thing to do was. Talking to the PCA gave her a fair chance to express her behaviors and correct them. Getting management involved was the best course of action afterward in dealing with a breach of confidentiality and discrimination. This may have prevented similar situations from occurring again.

Everyone is Involved

In an article about confidentiality breaches in clinical practice, a study was done involving 5th and 6th-year medical students at the University of Cordoba. This study involved direct observation in real situations where a breach of confidentiality occurred. They measured the type, severity, frequency of the occurrence, medical department, and the type of medical professional involved. The goal was to make health professionals and hospital management aware in order to implement measures to prevent future incidents. This study proved that although most incidents were committed unintentionally, every single healthcare personnel was in some way involved in confidentiality breaches.

Ethical Workplace Issues

A common legal definition of a whistleblower is someone, typically an employee, who discloses information, either internally (to managers, organizational hotlines, etc.) or externally (to lawmakers, regulators, the media, watchdog organizations, etc.), that he or she reasonably believes evidence: a violation of law, rule or regulation; a gross waste of funds; abuse of authority; o a substantial and specific danger to public health or safety.

Diverting narcotics is an ethical dilemma that is a common occurrence amongst health care staff. It can be easily missed due to improper wasting. In the hospital, the Pyxis will not allow you to waste a narcotic without getting a witness. Both nurses would review the amount to be wasted and would waste it right in the medicine room in a specific bin. I noticed some nurses will sign as a witness but would not stay to watch the other nurse physically waste the narcotic. That leaves opportunity for diversion. Also, it is easy to divert narcotics for patients on the CIWA scale because the amount of Ativan given is based on their behaviors and observed data. 2 mg can be taken out but only 1 mg could be given.

Diverting narcotics affects the safety and quality of care for patients. Not only are they not receiving appropriate doses to be therapeutic, but they are being treated by nurses under the influence. This poses a safety issue. Impairment can lead to medication errors and unsafe patient handling. Nonmaleficence was violated because the behavior of the nurses can potentially cause harm to patients. Patients consistently reporting unrelieved pain after receiving narcotics can potentially be an indication. Witness unusual behavior from the nurse involved can also be an indication of narcotic diversion. This unusual behavior can lead to medical errors and unsafe medical practice. One action as a moral agent in this scenario is to confront or report any unusual behavior to the charge nurse or nursing supervisor. Witnessing all wasted narcotics from start to finish will prevent many cases of diversion.

Lateral violence is another common ethical dilemma The term lateral violence refers to a pattern of workplace conflict in which confrontational behavior is targeted at 1 person by another employed at the same level of responsibility. The behavior is typically demeaning, humiliating, and diminishes the victim’s stature, resulting in social exclusion. Nearly all nurses experience lateral violence in their careers. One study of lateral violence found 97% of nurses surveyed reported lateral violence in their health care workplace as a common occurrence. The highest frequency of complaints focused on patterns of verbal abuse.

Lateral violence makes the work environment very uncomfortable and causes unnecessary emotional stress on those involved. Ultimately this can affect the quality of care provided to the patients. If the nurse dreads going to work due to bullying and conflict with fellow staff members, it can come across to patients. The ethical principle that is violated in this dilemma is fidelity. There is a reasonable expectation that basic respect will be shown to anyone, anywhere. Anyone who victimizes and singles out an individual is abuse. I was involved in lateral violence. I was new on the unit and a very outspoken staff worker mentioned I was pregnant to everyone at the nursing station. She had heard the news from my preceptor. I was embarrassed and upset because it was a secret I was not ready to share. I expressed to her that it was not her personal business to share. Instead of expressing remorse she turned most of everyone against me. I would hear her talking badly about me to other staff members and constantly belittling me due to my lack of experience. I did not report her to HR because I was afraid of retaliation. If I witness workplace bullying against someone else, I would report them to management or HR.

Keeping a patient’s private information confidential is the duty of all health care professionals. If there is a breach of confidentiality witnessed, it should always be addressed. Because it occurs so often; mostly without realizing, it is important to make each other accountable for how our comments can affect our patients. Limit discussions regarding patients to those who are directly involved in the patients care. Giving report in secluded areas where information cannot be overheard is ideal. Keeping patients’ information confidential demonstrates respectful and helps build upon trusting relationships amongst patient and staff.

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