Written by: Janesse Abreu & Rochel Boord
Case-Based Ethical Argument Essay
Assignment #1
A married female presented to the Emergency Department (ED) with a left upper extremity (LUE) injury which she claimed was due to a fall. Imaging of the LUE revealed a fracture that was consistent with a direct blow rather than a fall. The patient revealed to Ms. Jenkin that the LUE injury was the result of intimate partner violence (IPV): she was thrown downstairs by her husband during an altercation while he was under the influence of alcohol. The patient also reported that 2 young children were exposed to the IPV incident. Furthermore, the patient refused disclosure of the IPV incident via [its] documentation in her medical record. Of note, the patient is a former colleague of Ms. Jenkin, and both the patient and her husband are known to the staff of the ED.
The ethics question posed by the case above is: Should Ms. Jenkin respect confidentiality by honoring the patient’s request for non-disclosure of the IPV incident? The ethical principles most relevant to addressing the ethical question above are beneficence and autonomy. Furthermore, Ms. Jenkin should respect confidentiality by honoring the patient’s request for non-disclosure of the IPV incident based on the ethical principles of beneficence and autonomy.
Confidentiality refers to the agreement between the patient and the provider for the patient’s protected health information (PHI) to be kept private. The purpose of confidentiality is to establish or maintain trust and confidence in the patient-provider relationship (2). As such, respecting confidentiality involves actions that promote a therapeutic patient-provider relationship. These actions are consistent with the ethical principle of beneficence: the obligation to maximize benefit and minimize preventable harm (3). Respecting confidentiality by honoring the patient’s request for non-disclosure of the IPV incident upholds the ethical principle of beneficence in that it respects the patient’s personhood, avoids preventable harm, and promotes favorable clinical outcomes (2).
Respecting confidentiality would allow Ms. Jenkin to respect the patient’s personhood by honoring the patient’s truthful disclosure of the history of her injury and by expressing allegiance to the patient’s request for non-disclosure of the IPV incident (2). Failing to respect confidentiality would threaten the patient’s personhood (2), and this could lead to harms such as emotional and psychological suffering. Furthermore, respecting confidentiality would allow Ms. Jenkin to avoid preventable harms (2). Failing to respect confidentiality could risk inducing the very harm that the patient is actively trying to prevent by keeping such information private which, in this case, is the risk of harm to her husband’s career (2). Lastly, respecting confidentiality would allow Ms. Jenkin to promote favorable clinical outcomes by facilitating truthful disclosure of relevant information in the future. Truthful disclosure is necessary for proper patient management (1). Failing to respect confidentiality could prevent truthful disclosure of relevant information in the future, and this could lead to adverse clinical outcomes. Additionally, failing to respect confidentiality could deter the patient from seeking assistance in the ED in the future, which may also lead to adverse clinical outcomes. Failing to respect confidentiality could indirectly lead to adverse clinical outcomes by directly harming the therapeutic patient-provider relationship.
Respecting confidentiality upholds the ethical principle of autonomy in that it respects the patient’s decision for non-disclosure of the history of her injury (1). Autonomy states that patients have an obligation to take responsibility for their voluntary and informed decisions based on the principles of free action and effective deliberation, respectively (1). Autonomy as free action states that patients have the liberty to make voluntary decisions (3). Respecting confidentiality would allow Ms. Jenkin to respect the patient’s autonomy by allowing the patient to make a voluntary decision regarding whether or not to disclose the history of her injury, and by respecting said decision.
Furthermore, autonomy as effective deliberation states that patients are able to make informed decisions if they are able to understand and weigh out their options (1). Effective deliberation requires the patient to have decision-making capacity and to have all of the information necessary to make an informed decision: to understand the potential consequences such as the risks and benefits of each option (3). The patient demonstrated to be making an informed decision through effective deliberation: she weighed the risk of further harm to herself and the children against the risk of harm to her husband’s career. As such, respecting confidentiality would allow Ms. Jenkin to respect the patient’s autonomy by allowing the patient to make an informed decision regarding whether or not to disclose the history of her injury, and by respecting said decision.
One may counter that an obligation to beneficence is violated by respecting confidentiality in that non-disclosure of the IPV incident could reinforce violent behavior in the future, thus placing the patient at risk for further harm. Additionally, there may also be a risk of further harm to the children involved. The children may be directly harmed by IPV through physical abuse or indirectly harmed by IPV through emotional abuse (1). Failing to respect confidentiality would allow Ms. Jenkin to obtain professional help for the patient with the aim of preventing further harm to the patient and the children in the future. However, it is not clear whether obtaining professional help would, in fact, prevent further harm to the patient and the children in the future. It is also not certain that obtaining professional help would cause the patient to leave the abusive environment. It is possible that the risk of leaving the abusive environment is greater than the risk of staying in the abusive environment. It is also possible that obtaining professional worsens the abusive environment for the patient and the children by increasing tension and violent behavior between the patient and her husband.
In essence, it is not certain that failing to respect confidentiality is the best course of action for the best interest of the patient. What is certain is that failing to respect confidentiality would threaten the patient’s personhood which could lead to harms such as emotional and psychological suffering, induce the very harm that the patient is actively trying to prevent, and lead to adverse clinical outcomes by preventing future truthful disclosure of relevant information and by deterring the patient from seeking assistance in the ED in the future, as a result of damage to the therapeutic patient-provider relationship.
Analysis of the ethical principles of beneficence and autonomy with regard to whether or not Ms. Jenkin should respect confidentiality [as posed by the ethics question in the case above] demonstrates that the options of respecting confidentiality and failing to respect confidentiality both present mixed harm/benefit profiles. Nevertheless, the harm/benefit profile of respecting confidentiality is superior to the harm/benefit profile of failing to respect confidentiality. As discussed above, the ethical principles of beneficence and autonomy strongly support Ms. Jenkin’s option to respect confidentiality by honoring the patient’s request for non-disclosure of the IPV incident.
References
Jenkin, A, Millward, J. (2006). A moral dilemma in the emergency room: Confidentiality and domestic violence. Accident and Emergency Nursing, 14(1), 38-42.
Kirk, Timothy W. “Confidentiality.” In Nathan Cherny, Marie Fallon, Stein Kaasa, Russell Portenoy, & David Currow, eds. Oxford Textbook of Palliative Medicine. (5th ed.) New York/London: Oxford University Press, 2015. 279-284.
Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
