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SCENARIO A: A patient was upset on learning that his employer had obtained confidential medical information that had discussed with his general practitioner the day before. He refused to return to the doctor for further treatment and considered taking the case to court
1.0 Learning objective tested: Define patient privacy: definition and relation to patient autonomy
QSN1: Explain what you understand by the term ‘privacy’ [2 marks]
ANS1: An individual has a right to privacy that implies the right to make decisions about personal or private matters and blocking access to private information. Privacy and autonomy are closely related. Privacy rights define and protect an area in the life of the citizen from which the state is excluded. The physician can enter into this privacy only if there is an autonomous decision of informed consent. There are situations in which the Law permits invasion of a citizen’s privacy such as compulsory screening and treating of some diseases
2.0 Learning objective tested: Describe patient confidentiality: definition, what information is considered confidential, anonymized information, violation with / without consent, disclosure about the deceased).
QSN2: Explain what you understand by the term ‘medical confidentiality’ [2 marks]
ANS2: The patient voluntarily allows the physician access to private information in the trust that it will not be disclosed to others. This confidentiality must be maintained within the confines of the Law even after death of the patient. In routine hospital practice many persons have access to confidential information but all are enjoined to keep such information confidential
3.0 Learning objective tested:: Describe patient confidentiality: definition, what information is considered confidential, anonymized information, violation with / without consent, disclosure about the deceased).
QSN3: What is your view about disclosing confidential information about the deceased. Give reasons for your view. [2 marks]
ANS3: ANSWER OPEN
4.0 Learning objective tested: Discuss the basis/ rationale / justification of confidentiality: clinical care. Autonomy and privacy, fidelity, social basis, legal basis).
QSN4: List ONE reason that justifies medical confidentiality [2 marks]
ANS4: (a) Clinical care: If the patient is not assured that information revealed to physicians will be kept in confidence, he or she will not provide sufficient information to the physician for proper diagnosis and management. Such violation destroys future co-operation because the patient will hold back some information from the caregiver thus impairing correct diagnosis and appropriate management. (b) Autonomy and privacy: The patient has a right to keep personal information private and inaccessible to unauthorized persons. (c) Fidelity: It is part of the trust between the patient and physician that their professional relationship remains private. The psychological basis of fidelity is the private and privileged relationship of trust between the patient and the caregiver. Revealing secrets that occurred to a third party is a violation of the trust. If a person seeks advice and divulges secret information, that information is protected because the advisor is supposed to be trusted (d) The social basis lies in the prohibition of spreading rumors, and backbiting. (e) The legal basis is based on the law of contract, three Principles of the Law, and the Law of Property. Keeping medical secrets is part of the physician-patient contract; fulfilling a contract is an obligation in Islam. Revealing secrets injures the reputation of the patient and violates the Principle of Injury which states that an individual should not harm others or be harmed by others. Under the Principle of Hardship confidential information can be revealed in cases of necessity. The Principle of Hardship states that hardship mitigates easing of the rules and obligations. Necessity legalizes the otherwise prohibited. Therefore for purposes of treatment, information can be revealed to other healthcare workers. Information can also be revealed in pursuit of justice
5.0 Learning objective tested: Discuss truthfulness in clinical care: obligation to tell the truth, information patient does not need/want to know, partial disclosure / white / technical lies, giving bad news, the physician’s body language).
QSN5: Explain what a technical lie is and give your views about it [2 marks]
ANS5: Technical lies are statements that are apparently true and whose truth can be defended using data and reasoning but they contain an element of untruth that any person privy to the whole information will be able to discern. The physician may consider telling ‘white lies’ for the sake of the patient welfare. The physician should be guided in his communication by the background and understanding of a patient. Some patients can be given a lot of information and they do not get disturbed. Some types of information agitate patients. The prophet taught talking to each person according to his ability to understand.
CASE SCENARION B: The husband of a patient presenting with a breast lump instructed the surgeon to remove the breast immediately without taking a biopsy. The doctor refused and asked the patient to consent to biopsy by fine needle aspiration. The patient refused and threatened to sue the surgeon.
1.0 LEARNING OBJECTIVE TESTED: Discuss patient autonomy in medical decisions:
QSN1: Explain the term ‘patient autonomy’
ANS1: The patient has the right of autonomy which is control of what is done to his/her body. Autonomy is a basic human right that cannot be violated except in exceptional circumstances explained below. No medical examination or medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence. The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias their decision-making. [2 marks]
2.0 LEARNING OBJECTIVE TESTED: Discuss patient autonomy in medical decisions:
QSN2: Describe tests for capacity / competence (2 marks)
ANS2: The following are criteria (tests of capacity) are used to judge whether the patient is capacitous: (a) Understands what the procedure is. (b) Understands the reason for the procedure. (c) Understand the benefits and risks of the procedure. (d) Has the ability of judging and weighing the information before coming to a decision (e) Has sufficient memory to retain information given for a long enough period to enable effective decision making (f) Understands the consequences of refusing (4 marks)
3.0 LEARNING OBJECTIVE TESTED: Discuss patient autonomy in medical decisions:
QSN3: Explain the patient’s right to refuse treatment (2 marks)
ANS3: The patient is free to withdraw consent at a later time and this decision must be respected. Refusal of treatment is a human right that must be respected. Refusal to consent must be an informed refusal (patient understands what he is doing). Refusal of treatment should be documented properly. Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court. A patient who refuses a treatment has no automatic right to demand an alternative and may be more expensive procedure. [2 marks]
4.0 LEARNING OBJECTIVE TESTED: Discuss patient autonomy in medical decisions:
QSN4: Discuss issues of consent for physicians employed in prisons and armed forces (2 marks)
ANS4: Informed consent is still required for physicians in special practices such as a ship’s doctor, prison doctor, and doctors in armed forces. Police surgeons may have to carry out examinations on suspects without informed consent. [2 marks]
5.0 LEARNING OBJECTIVE TESTED: Discuss patient autonomy in medical decisions:
QSN5: Explain the term physician autonomy (4 marks)
ANS5: (a) Professional freedom and professional independence: The physician as a professional should be free in the exercise of his profession and his work performance can only be reviewed by his professional peers and not managers or administrators outside the medical profession. (b) Refusal of medical procedures based on conscience: The physician should be free to refuse undertaking procedures such as abortion if he feels that they violate his personal values.(c) Torture or degrading punishment: The physician should not forced against his will to participate in cruel or degrading punishments or torture.