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Confidentiality Gray Areas - a Burn Victim's Desire to Die
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correct answer is C. Your client has the right to have this information
kept confidential. C states inform your client of her options.
A, urge your client to leave her husband, is incorrect because,
even though this may be one good option of your client, it may also put her at
risk, and she may not be ready to make such a move.
work with the client to document the frequency, magnitude, and duration,
is incorrect because your client has more pressing issues of self-protection.
Answer B describes the taking of baseline measures for marking future progress
in behavior modification therapy, and this is obviously a low priority right now.
interview the husband, is incorrect because this course of action will
reveal to the husband that your client has informed you of his behavior. She had
indicated that this might pose a threat for her. This course of action is very
likely to be ineffective and actually to cause some violent behavior on the husband's
us look at some of the medical confidentiality gray areas...Legal Action Involving
Breaches of Patient Confidentiality. This is a partial list of a few selected
lawsuits in which patients alleged breaches of confidentiality.
♦ Legal Action Involving
Breaches of Patient Confidentiality
of Behringer v. Princeton Medical Center, 249 N.J.Super. 597 (1991). Behringer,
a surgeon at Princeton Medical Center, was diagnosed with AIDS. Behringer's chart,
which included several references to the diagnosis, was kept at the nurses station
on his floor with no special protection; his condition soon became widely known.
Behringer sued the hospital for its failure to take reasonable steps to protect
v. St. Clare's Hospital, (Kings County Supreme Court, New York, 1994). Velazquez
was admitted to St. Clare's Hospital in 1991. In 1992, while she was running for
election to U.S. House of Representatives, copies of her medical records were
distributed to the press, which reported on them. Velazquez sued the hospital
for breach of contractual and fiduciary duties of confidentiality, for wrongful
disclosure, and for negligence in maintenance of the security of the medical record.
v. Methodist Hospital, (Hancock County Superior Court, Indiana, 1992). According
to the complaint, Doe, who had tested positive for HIV, disclosed his HIV status
to paramedics when he was taken to the hospital after a heart attack. The paramedics
noted his status on their report, which became part of Doe's medical file. Hospital
employees revealed Doe's HIV status to his coworkers, and Doe sued the hospital
and some of its employees for invasion of privacy and other wrongful conduct.
v. Rutland Medical Center, (Vermont, 1994). O'Connor claimed that on two occasions
different hospital employees discussed her medical condition, without her consent,
with her husband and ex-husband, and she sued.
So the ethics audit question here
is, what is your confidentiality policy in discussing information with family
members, relatives, and significant others?
and a Burn Victim's Desire to Die
July of 1973 an unmarried 26 year-old-man, whom we shall call James, was severely
burned when he and his father set off an explosion from a leaky propane gas pipeline.
The father died before reaching the hospital, and James sustained second and third
degree burns over two-thirds of his body. He is now blind in both eyes, although
he might possibly be able to recover sight in one eye.
After nine months of treatment,
the tips of his fingers have been amputated, his hands are useless, he cannot
get out of bed by himself, and the burns are still not healed. In order to keep
the open burns from becoming infected, James must be immersed daily in a bath
of antiseptic solution. The baths are preceded by injections that make James unconscious,
but the dressing of the burns after his bath is still quite painful to him.
is an intelligent and articulate young man. He has persistently pleaded to
be allowed to leave the hospital and go home to die. He says that he will
not wait to die a natural death from the infection that would begin in the open
burns but would take measures to end his own life. He has recently refused permission
for further surgery on his hands.
physicians have called in a consulting psychiatrist with the intent to have him
declared incompetent, but the psychiatrist has concluded that James is rational.
James's argument for wanting to end his life is that he has been an active person,
has participated in sports, and is fond of the outdoors. He does not find enough
value in living blind and as a cripple to make it worthwhile to endure the painful
treatments and the problems of adjusting to a new lifestyle. James has asked the
physician to help him get out of the hospital, so he can go home and die.
the physician honor James' request? Let's apply the concepts discussed in this
♦ I. Factual
The physician must answer a number of factual questions before he
can make a decision. One of the questions is whether James could adjust to his
new lifestyle. James says he would never find life worth living as a disabled person, but the physician has access to histories of other victims of catastrophes
and will want to make a determination on his own of James' prospects for future
happiness. The physician will also want to know the law governing these situations.
What can he do legally without incurring unacceptable liabilities for himself
or the hospital? You may think of other factual issues that are important in the
Two important conceptual issues arise in the case. The first is whether
this proposed action is a case of suicide. Because James wants to end his life
by some direct means and out of concern for his own well-being, most people would
consider his action to be suicide. The second question, which is more difficult,
has to do with the concept of rationality. Is James rational enough to make such
a serious decision about his own future?
The physician has to have a clear concept
of what he means by rationality before he can answer this question. Of course,
factual issues can be raised here as well. The physician might have a clear concept
of what it means to act rationally but might still be puzzled about whether James
is acting rationally. If he defines rationality as involving, among other things,
making decisions on the grounds of all available evidence, he might still wonder
whether James fully understands the degree to which he will be able to manage
his own affairs at home. Nevertheless, having a clear concept of rationality is
an important first step in determining whether James is rational.
This case has two important moral issues. One is the morality of killing oneself. This question is especially interesting, because James is not dying.
Given sufficient time, the burns will heal, and James will be sent home. He should
be able to live out his normal lifespan, even though he will be handicapped.
second issue has to do with the obligations and prerogatives of the physician.
Does the physician have an obligation to help James get out of the hospital? Does
he have an obligation to help James end his life if he is asked to assist? Does
he have the right to try to keep James in the hospital if he thinks James is not
rational? Does he have the right to try to keep James in the hospital if he disagrees
with James's decision to end his life, even if he believes James is rational?
and Factual Statements
Recall that moral conclusions do not follow directly
from the facts of the case. For example, the fact that James will recover and
can eventually be sent home does not necessarily mean that his ending his life
would be wrong, although this consideration is relevant to the issue.
that the physician is prevented by law from directly administering a lethal injection to James at his request does not settle the question of whether he should legally
be allowed to do so. The fact that the physician may be opposed to all forms of
suicide does not necessarily mean that he should act to prevent James from killing
of Moral Statements
The moral questions at stake seem to exhibit the four
characteristics of moral statements.
First, the answers given to the moral questions
at issue prescribe the conduct that James and his physician should follow. The
statement that it is wrong for James to commit suicide implies that James should
not take any measures to end his own life. The conclusion that the physician has
an obligation to help James get out of the hospital implies that he should take
steps to achieve the goal.
Second, the moral statements made about this case are
ordinarily made from an impersonal standpoint. If we are making judgments about
the case from an observer's perspective, this impersonal standpoint can be assumed.
But, even if we take the physician's standpoint, we would presumably ask what
should be done based on his moral and professional obligation. Self-interest is
not a legitimate consideration unless it would apply to any other physician in
the same situation. If injecting James with a lethal drug would result in the
physician's incarceration, that consideration would appropriately carry some moral
weight. But, it would carry moral weight with any other physician in the same
Third, the moral issues have a serious and overriding importance. The
moral issues are more important than issues of medical etiquette or the aesthetic
questions regarding James's burns. They are even more important than the legal
issues in the case, because we might conclude that the laws should be changed
to accommodate our moral beliefs about what should be done.
Fourth, the issues
cannot be settled merely by an appeal to authority or to consensus or tradition.
Deciding whether it is wrong for James to take his life or whether the physician
should help him take his life involves more than taking a vote or determining
how the issue would have been decided in the past.
in Moral Philosophy
We can look at this problem from either a consequentialist
or a non-consequentialist perspective.
An egoist would ask about the consequences
of the alternatives for James' or the physician's self-interest. A utilitarian
would ask about the consequences for the general human welfare. Non-consequentialists,
such as natural-law theorists and advocates of the ethics of respect for persons,
would approach the issues differently. They would ask whether James' or his physician's
actions were in accordance with human nature or the respect due the person.
shall leave the steps of this determination for another time; the important point
is that the consequences of alternative actions are not the decisive point. For
example, by the standards of natural law, James should not kill himself, even
if the remainder of his life produces no benefit for him or anyone else.
in a discussion of the case, we would use the terms good or bad, intending thereby
to commend or condemn the actions, motives, or people involved. We would also
refer to the actions of the people involved as right or wrong, intending thereby
to classify them as morally obligatory (permissible) or as morally impermissible.
The concepts and distinctions we have discussed in this first chapter, then, are
an essential part of our moral discourse.
- Gellman, R., PhD. (1999). The Myth of Patient Confidentiality. Information Impacts Magazine.
Here is a question that revisits the "Duty to Warn," for purposes of
review. While in a therapy, Jill reveals that she is planning to physically harm
another client, whom she had met in a group you conduct. What is the best ethical
course of action for the social worker?
a. first, the therapist should alert
b. the therapist can do nothing because she/he is bound
by client confidentiality
c. the therapist should first warn the other client
d. the therapist should first tell the police of her client's intentions to harm
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