Comment of the Day: “‘The Ethicist’ and the Doctor”

"Your secret is safe with me, but I have to ask...what that stolen Renoir doing up there?"

“Your secret is safe with me, but I have to ask…what that stolen Renoir doing up there?”

Jeff Long scores his first Comment of the Day with a welcome excursion into the thickets of medical confidentiality. As I expected, many readers were troubled by my support of strict patient-doctor confidentiality as dictates by AMA medical standards. Jeff does an excellent job elaborating on why I (and the professions like law, medicine and the clergy) take the position they do. In professional relationships, trust is essential, and you can trust professions that approve of breaching confidentiality when a damaging secret is involved.

Here is Jeff’s comment, on the post “The Ethicist and the Doctor.”

“First, with regard to Matthew’s example of the cheating spouse who contracts an STD, I think it would probably be difficult to come up with a better example of “the system working as intended.” In the world where doctors respect confidentiality, at least one person gets treated. In the world where the doctor blabs to the world (or at least, to the spouse), there’s a good chance that nobody does. In fact, if the cheater forgoes treatment out of fear of exposure, s/he is putting the spouse at even GREATER risk than in the former scenario, since the STD goes untreated and has a larger window in which to infect the spouse. Certainly, the ideal world is the one where the cheater gets treated AND confesses to the spouse, but the onus for that lies with the cheater. It’s not the doctor’s place.

“My second point can, I think, best be summed up with the question “Have you read the classic Agatha Christie novel The ABC Murders (and/or seen the outstanding David Suchet adaptation)?” (mild spoiler alert) In this story, the quiet, unassuming but mentally unstable Mr. Cust suffers regular blackouts due to a war injury, and genuinely comes to believe that he is a serial killer who commits crimes during his memory lapses (more spoiler: he is innocent). Obviously, fiction isn’t real life, but sometimes it is better at making the point. As a real life parallel, consider one of the most famous unsolved crimes of the 20th century (at least in North America), the Black Dahlia murder. Wikipedia says that over 60 people falsely confessed to the crime; to this day, there has been no conviction. The upshot is that self-made confessions to crime are not in fact particularly reliable, nor are they particularly uncommon; and I think this is even more true for individuals who are seeking help for their mental health (which seems to be the case here; the patient was suffering headaches for what may have been largely psychological/stress-related reasons). It seems to me that medical ethics as Jack espouses here them are both perfectly appropriate and necessary in order for these sorts of patients to get the care they need without the fear of a panicky doctor reporting them to the authorities on flimsy evidence.

“I don’t think anyone contests that exceptions can’t be made in truly exceptional circumstances. If, for example, a patient comes to a doctor and says, “Jeff is on death row for murder right now, and I’m the culprit. And by the way, here’s half the victim’s body, which was never found because I’d been hiding it in my closet. You’ll find the DNA is a perfect match to the other half of the body that was left at the scene,” then probably the doctor is okay in reporting this and submitting himself to professional discipline, which will almost certainly let him off. But the vastly more common scenario of vague confessions and self-recriminations from a patient who may be suffering mentally? That’s nowhere close to the line, and medical ethics exist to remind doctors of this. The law may not be perfect, but it IS pretty rigorous; so if there’s any uncertainty at all, the doctor needs to be reminded this is not his call to make.

“To be fair, we don’t have enough information from the doctor’s anonymous letter in this case to say for sure whether it is closer to the exceptional or the non-exceptional scenario, but my guess is that the prior probability combined with the mere fact that the doctor was sufficiently uncertain to ask a newspaper columnist in the first place strongly suggests the latter.”

9 thoughts on “Comment of the Day: “‘The Ethicist’ and the Doctor”

  1. This would never happen but would like to hear from actual doctors who have faced this dilemma, and if they’ve ever spilled the truth to a third party.. And if psychiatrists behave different than other M.D.’s.

  2. In terms of the STD question, there is a way to circumvent the doctor’s requirement for confidentiality – all laboratories are required to report positive results for certain infectious diseases (which ones vary by state, but usually STDs are included) to the department of health. Milder STDs they just track for reporting purposes, but for HIV and other more life-threatening diseases, the department of health then interviews the patient and obtains a list of prior and current sex partners. The partners then receive a letter in the mail informing them that they have been exposed to the disease in question and should be tested.

  3. But MC, the whole point of things like confidentiality requirements is that they are considered worthwhile. If you’re suggesting that a doctor should figure out a way to make sure the spouse knows without TECHNICALLY telling them, then isn’t that in the same spirit as doing it themselves?

    Of course, I may be misreading you- the other interpretation is that you mean through natural channels and no specific effort of the doctors the spouse will find out ANYWAY, so the doctor shouldn’t worry about it, then I agree.

    • Your second interpretation is what I mean – the doctor has no choice in the matter – the lab doesn’t consult them before notifying the department of health. Granted, most doctors don’t disclose this to their patients before testing them, but I think that’s mainly because most doctors don’t realize the whole process.

      • Ah, OK. The word “circumvent” made me think you meant “Well, I can’t TELL the patient this but I can make darn sure he knows anyway!” Carry on, sir.

  4. “In terms of the STD question, there is a way to circumvent the doctor’s requirement for confidentiality – all laboratories are required to report positive results for certain infectious diseases (which ones vary by state, but usually STDs are included) to the department of health. Milder STDs they just track for reporting purposes, but for HIV and other more life-threatening diseases, the department of health then interviews the patient and obtains a list of prior and current sex partners. The partners then receive a letter in the mail informing them that they have been exposed to the disease in question and should be tested.”
    ********************

    I was going to post this as well, but I haven’t worked in Laboratory Medicine since before the newest HIPAA rule and wasn’t sure if the reporting guideline was any different as a result. (At least in PA)
    But yes, all labs were required to report sexually transmitted diseases and then the state followed the trail.

    We were also required to report certain types of foodborne illnesses (esp. in institutions), including Hepatitis.
    This is primarily to avoid outbreaks and, in the case of food, to track down improper food handling or employees carrying certain pathogens.

    On another note, there’s been a discovery in Japan of an antibiotic-resistant strain of Gonorrhea:
    http://www.npr.org/blogs/health/2011/07/12/137797153/super-resistant-gonorrhea-strain-found-in-japan
    Not cool!

  5. “But MC, the whole point of things like confidentiality requirements is that they are considered worthwhile. If you’re suggesting that a doctor should figure out a way to make sure the spouse knows without TECHNICALLY telling them, then isn’t that in the same spirit as doing it themselves?”
    ***********
    The state health departments do what they do to keep the community at large safe.
    Some pathogens, such as MRSA are also reported to the CDC.

    • Oh, I understand that. My initial reaction was thinking that MC was encouraging doctors to manipulate what/how they report to “get around” pesky confidentiality guides. His actual meaning, that the doctor doesn’t have to worry because the health department will follow their own guidelines, I have no problem with at all.

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