Ethics: the study of the general nature of morals and of specific moral choices; the rules or standards governing the conduct of the members of a profession.
American Heritage Dictionary, 1994
In my residency, we were aware of the ethics of medicine. Specifically, we knew that it was inappropriate to discuss patient information in public. Physicians of my generation, like those who came before and have followed, have generally strived to maintain this age-old tenet of the practice of medicine. We knew this from having learned the following section of the Hippocratic Oath (Fifth century B.C.):
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.1
Or we know it from the simplified line in the Declaration of Geneva (adopted in 1948, amended many times since) that many of us recited upon graduation from medical school:
I will respect the secrets that are confided in me, even after the patient has died.
Despite that most physicians paid attention to this expectation, sometimes we have allowed privileged information to slip out at inopportune times. In 1996, the U.S. Congress came to the rescue by passing HIPAA – the Health Insurance Portability and Accountability Act. President Bill Clinton signed HIPAA into law. The law essentially provides for the continuation of health insurance for citizens when they change or lose their jobs. It also requires standards for electronic health information sharing. It stipulates what is protected health care information – that which cannot be revealed except in an appropriate health care setting. This protected health care information is essentially all that Hippocrates realized, some 2,500 years ago. One might wonder that the acronym “HIPAA” shares the first three letters of Hippocrates’ name.
A couple interesting episodes have occurred in the last few years of my practice, in which a physician anesthesiologist inappropriately revealed privileged information. Because of HIPAA, each of these incidents was thoroughly investigated on the local level. They will be shared here merely to highlight how we, despite our best intentions, might occasionally slip in maintaining the highest of ethical standards.
The first case involved a gentleman in his 60s who presented for a surgical procedure. An attending physician anesthesiologist had reviewed his chart and then had taken a group of medical students into the patient’s room for the preoperative visit. The patient had a friend in the room with him. The attending physician recited to the medical students a list of the patient’s medical problems, including that the patient had hepatitis B.
After his discharge, the patient complained to the hospital about this visit and the manner in which the attending physician had revealed his history of hepatitis B. This was information the patient had not shared with his friend, and he was upset that the attending physician had revealed this privileged medical history. It took several phone calls and in-person meetings to reach an agreement with the patient. In the end, his main request was that the attending physician anesthesiologist provide him with an apology. It is amazing that such a small act of contrition could carry so much weight yet be so difficult to achieve.
After this incident, we began asking patients who had guests or family in the room when they were being interviewed if it was O.K. with them that we would ask potentially sensitive medical history questions. This gave the patient the option of saying no, at which time we would respectfully ask the visitors to leave the room. Amazingly enough, even with this option, patients have been upset that privileged information has been revealed.
On two separate occasions, physician anesthesiologists have asked patients if they had any concerns about discussing their medical history in front of family or visitors. Both times the patients answered no. But it would not be a good story unless things did not turn out the way we expect.
A female patient presented for a procedure. Appropriately, the physician anesthesiologist reviewed this patient’s history and discovered she had HIV and was taking antiretroviral therapy. The physician asked her if she minded discussing her medical history in front of a visiting family member. The patient said no. The physician asked if the patient had taken her antiretroviral medications that day. Unfortunately, the patient had not discussed with the family member that she had HIV, and the family member recognized that fact with the mention of the antiretroviral therapy. The patient was upset and embarrassed that her family member discovered the fact she had HIV.
In this case, the physician immediately notified his superiors about what had occurred. Nevertheless, heat rained down on the physician for this “HIPAA violation.” Luckily, it was well documented and witnessed that he had asked the patient’s permission to discuss her medical history. Still, this brings up the question: what if the patient does not understand what we are asking or what our questions might reveal?
The third patient experience was much like the second, only it occurred at a different hospital and the patient did not have HIV, but rather another disease he did not want revealed. Nevertheless, he had agreed to discuss his medical history in front of his family. They were surprised to learn of his diagnosis. The outcome was much the same. He was upset and complained to the hospital. Again, the physician anesthesiologist was somewhat sheltered by the fact that he had asked for permission to question the patient. Again, the question is raised: what if the patient does not understand what we are asking or what our questions might reveal?
My purpose is to highlight this aspect of how we, as professionals, might unwittingly reveal privileged information, even when given permission by the patient to do so. Should we always ask visitors and family to leave the room before we question the patient? Most of the time, the patient derives comfort from the presence of family. Thus, asking the family or other visitors to leave might be the ethical action to take, but it may also increase the anxiety of both the patient and the visitors. Nevertheless, if the patient gives me permission to question him or her in the presence of family or friends, that is what I do.
1. Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation. Supplements to the Bulletin of the History of Medicine. 1943;1:vii.