Dear Editor,
Richard Griffith's Legal column on electronic health records and maintaining patient confidentiality was thoroughly informative (Griffith, 2019).
Confidentiality, as stressed by Griffith, is a fundamental principle of professional ethics for clinicians and nurses and also a legal necessity. Confidentiality is instrumental in preserving patients' trust in health professionals. Its importance is stressed in the Hippocratic oath (Oxtoby, 2016), the Geneva Declaration (Parsa-Parsi, 2017) and by the General Medical Council (GMC) (2017). However, at times, breaching confidentiality is necessary, as specified by the GMC (2017).
When disclosing information about patients with impaired capacity, it is important to keep their best interests in mind. Seeking assistance from independent mental capacity advocates, those individuals holding lasting powers of attorney, and court-appointed deputies is advisable, especially when multidisciplinary teams and next-of-kin are involved (Ridley, 2001; Moskop, 2006; Blightman et al, 2014).
Sensitive clinical information about children can be shared with responsible parents, keeping in mind the level of understanding and best interests of the child (Gillick, 1988; 1994). Children should be encouraged to involve their parents in their treatment.
Any suspected abuse should be reported, taking account of the fine line that separates reporting authentic incidents as opposed to making ill-founded accusations, the latter leading to significant distress (Blightman et al, 2014; Taylor et al, 2018).
Legal issues related to national security and driving offences require disclosure to the police or the courts (Police and Criminal Evidence Act 1984; Prevention of Terrorism Act 2005; Road Traffic Act 1991) (Hunter v Mann, 1974; Coggon and Wheeler, 2010).
Doctors are required to provide third-party statements regarding medical management to employers, lawyers, coroners and insurance companies.
The legal team of ‘W’, who was convicted of killing and wounding several people, had approached Dr Egdell, an independent psychiatrist, to provide an expert opinion to support that he was harmless, in order to facilitate his transfer to a regional unit. However, Dr Egdell was of the opinion that ‘W’ was still dangerous and in order to protect the public, highlighted his report to the relevant authorities. When a motion of ‘breach of confidence’ was brought against Dr Egdell by ‘W’, the Court of Appeal supported this breach in the interest of public safety (W v Egdell, 1990).
Clinicians are considered negligent for failure to disclose confidential epidemiological information of specific communicable diseases (Public Health (Control of Disease) Act, 1982) in the interests of public safety. In such situations, they are required to act reasonably, balancing their duty both towards patients and the general population. When in doubt, advice should be sought from Caldicott guardians, defence unions or legal authorities. However, if more than the required information is disclosed, disciplinary proceedings can arise for inappropriate breaches (Z v Finland, 1997 and Cornelius v De Taranto, 2001) (Curtice, 2009).
Anonymous information regarding communicable diseases (HIV, tuberculosis, hepatitis B and C) should be shared with the appropriate authorities for surveillance. Although the AIDS (Control) Act 1987 precludes this from being notifiable in the UK, possibilities of reckless transmission and its life-changing consequences in others make this controversial, hence disclosure may be needed to relevant authorities. Where possible, patients should be taken into confidence and asked to consent to disclosure (Curtice, 2009; Venter et al, 2014).
To summarise, when disclosure is contemplated, each case should be considered on its own merit and doubts should be clarified with the appropriate authorities before breaching confidentiality.