Does patient confidentiality always prevail?
You have been working at Pinehills Prison and Corrections Centre as the in-house physician for approximately six months. Being a physician in a prison has required you to slowly build a sense of trust with the inmates (many of whom suffer from serious psychological illness) over a long period of time. The process has been arduous and often emotionally draining, but you finally feel like you are building a positive rapport with the some of the inmates and have seen a steady improvement in both their physical and mental health as a result of your ongoing appointments.
During your most recent routine visit you notice that one of your patients, Allen, has drugs on his person as well as a knife and other contraband. Possession of contraband in prison is illegal yet, the drugs and contraband pose no direct threat to the other prisoners or prison staff. However, the knife, in conjunction with the aggressive mindset of your patient, poses a very real threat, if not probable risk, to other individuals in the prison. You know that reporting Allen for all of this contraband will almost certainly destroy the trust that he has learned to place in your medical expertise and also runs the risks of generating and spreading distrust towards you among other inmates.
Do you report the drugs, knife and other contraband or should patient confidentiality prevail ?
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Sample answer to MMI medical interview question: an ethical dilemma.
A predetermined covenant of confidentiality characterizes the physician-patient relationship. Professional communications between physicians and patients are statutorily protected as confidential. A routine physical examination is part of the confidential communication, like information obtained by taking a medical history and data entered in the patient’s health record. Health professionals have an interest in maintaining confidentiality so that patients will feel comfortable in revealing personal but necessary information. Prisoners do not possess full constitutional rights to privacy, but they generally retain rights to privacy when there is a special relationship between communicants, such as the physician-patient relationship. In fact, respect for confidentiality is particularly important in a prison hospital setting, in which patients feel distrust because physicians are often employed by the incarcerating institution.
Clinical autonomy for health professionals in the prison setting is essential for good medical practice. Physicians working in prisons also retain the privilege of confidential interactions with patients, although the prison authorities may try to pressure doctors to supply information. Even if physicians are employed by the prison, their first responsibility is to their patients. The circumstances in which to give privileged information to prison authorities remains the physician’s decision.
Possession of illegal goods vs. patient confidentiality
The finding that contraband detected during an examination has the appearance of drugs and paraphernalia, like all results of the examination, is privileged information to be treated confidentially. The right to privacy supersedes a duty to report the discovery because there is no imminent threat to others. In contrast, the weapon harbored by the prisoner represents an imminent threat to other prisoners and to prison staff. Thus, upon discovering a sequestered weapon during the course of a routine examination, the physician has a ‘duty to warn’. According to case law, when the physician believes that a significant threat of harm exists, the duty to warn takes precedence over the patient’s right to privacy.
The case of prisoner Allen raises the issue of the point at which to draw the line between the duty to protect the public and the duty to protect patients’ privacy. Although legal guidelines can assist the physician in making the choice, the health professional must rely on a guiding principle of the medical profession: Where no danger to others exists, patients come first.
The possibility of discovering contraband during routine examinations of prisoner patients reinforces the need for informed consent at several stages. First, prisoner patients should be evaluated and treated only after they provide informed consent, unless they are incompetent. Before an X-ray is taken, they should be informed that it can demonstrate metal and other foreign bodies, and their agreement to the procedure should be obtained. Second, if a concealed weapon is discovered during a routine examination, the prisoner patient should be informed that the discovery will be reported and given the opportunity to surrender the weapon to authorities before more forcible means are taken to remove it. If Prisoner A is harboring drugs and a needle, drug use is quite possibly contributing to A’s health problem. It is the physician’s responsibility to educate A about the potential harm of drug use.
Thus, the ideal solution would be to deal with the knife separately from the drugs and other contraband.
C. Levine, Cases in Bioethics.