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President's Forum"Confines of Confidentiality"
There are however confines to confidentiality. As a guide, medical information may be given if one or more of the following are present:
1. Needed in the course of care of the patient,
2. With the patient’s consent,
3. Under statutory compulsion,
4. In the ‘higher good of society’.
However in modern medical practice, ethical conflicts do arise on this duty of confidentiality. Two recent letters received by SMA, one from a doctor and another from a member of the public, regarding disclosure of information and patient’s consent are good case studies.
The doctor wrote on 14 January 1999 that "it has now become common practice for third party payers and insurance companies to demand that diagnosis be stated on the claim form before the amount claimed can be approved and paid to the medical practitioner submitting the claim. The patient’s consent is not sought. If left unchecked, this practice will further erode the goodwill in the doctor-patient relationship in Singapore. The medical profession is covertly aware of this practice but has chosen a conspiracy of silence". Doctors "want to do the right thing, only to find themselves shut from the ‘contacts’ ". A member of the public also wrote on 3 February 1999 regarding her "Hobson’s Choice" on medical benefits when she joined a multinational company. She was asked to sign a statement that read as follows, "I hereby authorise my doctor, medical practitioner, hospital or clinic by whom or where I have been observed or treated, to give particulars about my whole medical history to the company’s benefits service centre. A photostat copy of this authorisation shall have the full effects of the original authorisation."Medical Ethics is based on the principles of beneficence, non-maleficence and respect of patients’ autonomy. It is clear that the duty of the doctor is to the patient, not the third party payer, whether he is the employer or a relative. If the patient’s consent is not given, the doctor should not provide medical information independently to the payer. Certainly even if
" Medical Ethics is based on theprinciples of beneficence, non-maleficence
and respect of patients’ autonomy. "
information must be given when consent is given, the doctor should take care that only those contextually relevant be provided.
If the patient has legally and willingly given up his privacy and autonomy in exchange for the payment of his or her medical bills, it can be argued that providing such information to assist in the patient’s claims for benefits would be ethically correct. However, the physician’s role as an advocate for the patients’ and society’s welfare cannot end there. Unfettered disclosure such as that dictated by the pre-signed consent given above, can be used to discriminate against the patient, undermine the trust in the doctor-patient relationship and the traditional principles of beneficence and non-maleficience.
The confines of confidentiality are increasingly being challenged. The vulnerability of information in the era of computerisation and proliferation of information technology and the sharing of patients’ care amongst numerous professionals and institutions have also been highlighted by Dr Chew Chin Hin in the 1998 SMA Lecture. The medical profession must take stewardship to ensure that the balance must still be in the patient’s best interest. In this task, it needs to engage other stakeholders such as commercial healthcare providers, employer groups, workers’ unions and third party payers. Doctors must also be educated to be patient advocates for patients’ autonomy in the light of the new practice milieu.
The 39th SMA Council has recommended the setting up of a SMA Centre for Ethics and Professionalism to spearhead initiatives such as these. There should be a partnership for health, not a "conspiracy of silence".
REFERENCE1. Ethics manual of the American College of Physician Annals of Internal Medicine 1 Apr 1998.
DR CHEONG PAK YEAN