Autonomy

1
Autonomy Confidentiality
Dr Leena Al-Qasem
2
Autonomy

3
A few cases

4
Case I

• You are caring for a patient with cancer. She is
  refusing to undergo surgery or receive
  chemotherapy for the treatment of her condition.
  What would the right action be in this case?

5
Case II

• A patient is being treated by you for a certain
  condition. He wishes to use alternative forms of
  treatment for this condition, treatment which you
  do not believe is effective, due mainly to lack
  of scientific evidence. Moreover, you believe
  that the alternative treatment might interfere
  with the standard treatment and cause the
  patients condition to worsen. How you would
  handle this case?

6
Case III

• Mr. C. (42 years old) is brought by his wife to
  the emergency department (ED). He is stuporous,
  with severe diabetic ketoacidosis and pneumonia.
  Physicians prescribe insulin and fluids for the
  ketoacidosis and antibiotics for the pneumonia.
  Although Mr. C. was generally somnolent and
  stuporous, he awoke while the intravenous line
  was being inserted and stated loudly "leave me
  alone, No needles and no hospital. I'm OK". His
  wife urged the medical team to disregard the
  patient's statements saying "he is not himself"

7
Principles of ethical guidelines

• Autonomy
• Beneficence
• Nonmaleficence
• Social Justice

8
Autonomy

• Self-determination, independence, and freedom.
• physicians should take steps to promote more
  patient autonomy, as by disclosing information
  and helping patients deliberate
• With regard to health care, autonomy justifies
  the doctrine on informed consent

9
Refusal of unwanted medical interventions

• Informed, competent patients may refuse unwanted
  medical interventions. Such refusals respect
  patients bodily integrity, patients may not be
  subjected to invasive interventions without their
  consent.

10
Choice among alternatives

• In addition patients may choose among medically
  feasible alternatives. e.g. choosing whether to
  have an x-ray or choosing among several drugs for
  a condition do not implicate the patient's bodily
  integrity in a manner similar to surgery.

11
Conflicting choices

• Competent, informed, patients have the right to
  make choices that conflict with the wishes of
  family members or the recommendations of their
  physician.

12
Autonomy

• Treating patients with respect entails several
  ethical obligations
• Physicians must respect decisions of autonomous
  persons.
• respect for persons with impaired decision making
  capacity
• avoiding misrepresentation, maintaining
  confidentiality, and keeping promises

13
Autonomy

• Who would we consider as autonomous individuals?

14
Autonomy

• Autonomous individuals are
• adults
• have decisional making capacity
• act intentionally
• are informed
• are free from interference and control by others

15
Autonomy

• Why would individuals lose their decisional
  making capacity?

16
Autonomy

• Age
• Illness
• Medication/drugs

17
Autonomy

• Physicians should still treat these patients as
  persons with individual characteristics,
  preferences, and values.
• Decisions should respect their preferences and
  values as far as they are known.

18
Autonomy

• All patients, whether autonomous or not should
  be treated with compassion and dignity. Thus
  respect for persons includes responding to the
  patient's suffering with caring, empathy, and
  attention.

19
Autonomy

• may be justifiably restricted for several
  reasons
• 1. person is incapable of making informed
  decisions. Respecting autonomy lt important than
  acting in the best interest of the patient.

20
Autonomy

• may be justifiably restricted for several
  reasons
• 2. constrained by the needs of other individuals
  or society at large.

21
Autonomy

• may be justifiably restricted for several
  reasons
• 3. not free to act in ways that violate the
  autonomy of other people, harm others, or impose
  unfair claims on society's resources.

22
Questions about autonomy

23
Confidentiality

24
Cases

25
Case IV

• A 32 years old woman is admitted to the hospital
  after a serious automobile accident. She is
  disoriented and confused. The patient's sister
  requests that the patient's husband not be given
  any information. The patient has previously told
  the physician about her hostile divorce
  proceedings. The husband, however, learns that
  she is hospitalized and inquires about her
  condition.

26
Case IV

• A 61 years old man is diagnosed with metastatic
  cancer of the prostate. He refuses hormonal
  therapy and chemotherapy. He instructs his
  physician not to inform his wife and says he does
  not intend to tell her himself. The next day, the
  wife calls to inquire about her husband's health.
  

27
Case IV

• A 32 years old male is diagnosed with bacterial
  meningitis. After the physician explained his
  diagnosis to him, the risks and benefits, the
  patient refused to be treated for his illness
  and insisted on going home.

28
Case IV

• A woman arrives at the emergency department with
  serious contusions on the right side of her face
  and two teeth missing. Her nose appears to be
  broken. Her husband accompanies her. He explains
  that she tripped on the carpet and fell down a
  flight of stairs. She affirms his story. The
  emergency resident suspects spousal abuse. He
  does not know the couple, however, and judges by
  their distress and manner that they appear to be
  respectable citizens.

29
Confidentiality

• Patients reveal sensitive information
• -emotional problems
• - alcohol and drug use
• - sexual activities
• The information disclosed may be of interest to
  parties outside the medical relationship.
• The presumption is that physicians maintain
  confidentiality

30
Confidentiality

• Traditionally, ethically, and legally guarded
• Physicians are obliged to refrain from divulging
  information
• Take reasonable precautions to ensure that such
  information is not inappropriately divulged

31
Reasons for confidentiality

• Shows respect for patients.
• Has beneficial consequences
• Patient
• Physicians
• Society

32
Difficulties with confidentiality

• Professional indiscretions
• Confidentiality has been treated rather
  carelessly in modern medical care.
• Speak about patients in public places
• hospital elevators and cafeteria.
• Cell phone conversations

33
Difficulties with confidentiality

• Medical records
• Records may not be well secured
• Accessible to many persons

• attending physicians
• house staff
• Students
• Consultants
• Nurses
• social workers
• Pharmacists
• Secretaries
• medical records personnel
• insurance company employees
• Quality care reviewers

34
Difficulties with confidentiality

• Computerized records
• enhances statistical information
• facilitates administrative tasks
• availability of medical record information to
  interested third parties
• many people have access to medical records
• information can be obtained from any computer
  station and information on a large number of
  patients can be accessed at once

35
Difficulties with confidentiality

• Other new communication technologies
• Fax
• e-mail

36
Waivers of confidentiality

• Patients commonly give physicians permission to
  disclose information about their condition to
  others e.g. insurance companies.
• Insurers often require clinical information
  before they reimburse physicians or hospitals.

37
Waivers of confidentiality

• Patients may not appreciate that signing a
  general releases allows the insurance company to
  disseminate the information further.
• Insurance companies generally place patients
  diagnosis in a computer database that is
  accessible to other insurance companies or to
  employers without further permission from the
  patients.

38
(No Transcript)
39
Overriding confidentiality

• The potential harm to identifiable party is
  serious
• The likelihood of harm is high
• There are no less invasive alternative means for
  warning or protecting those at risk

40
Overriding confidentiality

• Allows the person at risk to take steps to
  prevent harm
• Harms to the patient are minimized and
  acceptable.
• Disclosure limited to essential information

41
Questions about confidentiality
42
Summary
43

• Respect choices of autonomous individuals
• Autonomy may be justifiably restricted
• Confidentiality is preciously held principle in
  medicine
• May be breached under certain circumstances

44
Thank you