What has happened to patient confidentiality? - Ethics and the Clinical Laboratory

In an early 19th-century code of medical ethics,we read the following: "Patients should be interrogated concerning their complaint in a tone of voice which cannot be overheard." (1) This statement represents an effort to formalize a policy protecting patients from abuse of diagnostic information obtained on their behalf. The principle of confidentiality, which acknowledges respect for each patient's privacy, is fundamental to all health care.

Such privacy promotes the physician--patient relationship by buiding and strenthening communication between them. Yet the concept of patient confidentiality is not what it was. Is it dead, as some have suggested? Or is it merely crumbling beneath the weight of more urgent issues?

The 1803 code of medical ethics quoted above addresses the physician alone. What of the medical technologist working the modern laboratory, or the vast web of computer access systems connecting laboratory output to other health care workers? Today, massive amounts of data originating in the clinical labs of health care institutions are easily accessible not only to all medical technologists but also to nurses, pharmacists, and other hospital employees. As the producer of such data, the laboratorian is on the front lines of a growing conflict between confidentiality and other competing interests.

* Eroding concept. Policy regarding patient confidentiality has been expanded to include the entire medical record. The 1989 edition of the American College of Physicians' Ethics Manual states: "The patient's right to the confidentiality of his or her medical record is a fundamental tenet of medical care. The physician must not release information without the patient's consent, unless required by the law or fulfilling a duty to warn another. Confidentiality should be protected to the greatest extent possible, consistent with the duty to protect others and to protect the public health." (2)

Thus the value of confidentiality to the patient remains worthy of note by physicians nearly two centuries later. The problem is that confidentiality is becoming difficult to maintain in the face of a proliferating array of other compelling values. Among these is the patient's own best interest in receiving the best possible care.

Health care is no longer delivered by a single practitioner whose decisions regarding confidentiality are absolute. Instead, the physician is part of a team in which hundreds of other people may directly or indirectly contribute to treatment. The advantage is having a large group of specialized personnel working on the patient's behalf. The tradeoff is diminished confidentiality.

* Money. Another patient benefit that impedes confidentiality is the economic assistance provided to patients by their health insurance. Few patients could afford to pay out of pocket for medical bills incurred by accidents or major illness. Skyrocketing health care costs have led to the demand for access to the patient's chart by all third-party payers.

The irony is that while these groups are permitted easy access to laboratory information, patients who want copies of their own records must submit involved written requests that may takeweeks to process. Insurance companies and HMOs are privy not only to laboratory results but also to intimate details gleaned from the patient's chart, including the physician's personal comments on the patient's attitude and degree of cooperation. Occasionally this information may work against the patient, especially if used to deny payment. As a result, although the economic benefits of private and public financial assistance for health care are clear, the patient pays a stiff price in other ways. Consequently, another chip of patient confidentially is whittled away.

* Good of the many. Patient confidentiality can become overshadowed when the good of society as a whole is placed above that of the individual. These issues include debates over screening the population for HIV infection and other contagious diseases in the workplace and elsewhere, and screening for drugs of abuse or genetic predisposition to certain diseases. A host ofethical questions surfaces, including the problem of confidentiality. What testing should be done, and who should be allowed to see the results?

As a sentinel of laboratory output, the medical technologist can speak meaningfully about these issues. Decisions made regarding these questions will affect the laboratory worker directly while affecting the ethical context of the laboratory overall. Being in this unique position places the edical technologies in the forefront of many conflicts that relate to patient confidentiality.

* In the loop. To the extent that aspects of the patient's condition can be deduced from laboratory data, medical technologists are in the loop of confidentiality. Laboratory policies and guidelines imply that any conversation that may be publicly overheard opens the possibility of a potential breach in confidentiality. To prevent that breach, laboratory data must be guarded against the unauthorized release of private information in spoken, written, or electronic form.

The original intent behind laboratory codes of confidentiality was to prevent the consequences of "loose talk." If "loose lips sink ships" then the "ship" in this case is the preservation of privacy.

A great temptation to abandon confidentiality occurs when the patient is a celebrity. The public tends to be insensitive to the personal harm caused by leaks of information about public figures, regarding their lives as the tabloids do: as public property. The news media are especially guilty of seeking out and releasing improper medical information.

A case in point occurred in the 1950s when President Eisenhower was hospitalized briefly for a minor illness. The following day, inapproriate detailsabout his condition appeared on the front page of The New York Times, including such intimate details as how many times he had used the bedpan. Indignation about this blatant breach of privacy rippled through the medical community.

* When to share data. For the private citizen, divulging laboratory results can be equally damaging, especially when the data concern information about cancer or sexually transmitted disease, especially AIDS. In such cases it is crucial that the medical technologist preserve the patient's right to confidentiality.

Does a higher ethical mandate ever compel the medical technologist to reveal laboratory information? Yes. One particularly delicate situation involves the laboratorian who feels obliged to blow the whistle on a physician. The medical technologist is among the few hospital employees who is sufficiently knowledgeable to detect a deterioration of patient care simplyby reviewing test results. Strategic placement in the laboratory permits this staff member free access to all pertinent patient data, including the condition of specimens submitted and the times at which they were obtained.

In one such case, a medical technologist confirmed a critical value for a patient's activated partial thrombolplastin time (APTT) and called the nurse to report the findings. The next day, a repeat test showed that the value remained critical. On the third day, when the value was found to be higher yet, the medical technologist notified the pathologist of the results.

As it turned out, not only had the nurse in charge failed to notify a physician, but the vacationing physician never returned to review the laboratory results. As a consequence, the patient was overdosed with heparin. Fortunately, prompt treatment corrected the problem. Without the medical technologist's intervention, however, severe damage or even death might have resulted. The conscientious and ethical use of medical information in cases like this has great validity in the preservation of high-quality patient care.

Another situation in which it is a laboratorian's duty to share medical information occurs when a coworker has been exposed to infectious or toxic material. In such cases, it is appropriate to release results of HIV or hepatitis tests done on those specimens. Despite our best efforts to install universal precautions, accidental needlesticks do occur. our responsibility dictates that the employee deserves the benefit of laboratory information that directly involves his safety.

* Precarious balance. Like many other health care workers today, the medical technologist balances precariously between the ideal of strictly preserving patient confidentiality and increasing demands to release patient data. General hospital policies stating when and how to report incidental critical values are of no help concerning HIV testing or suspected physician incompetence.