Breaching confidentiality to protect the public: evolving standards of medical confidentiality for military detainees

Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings have raised the profile of decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health.     

Breaching Confidentiality to Protect the Public: Evolving Standards of Medical Confidentiality for Military Detainees

Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings have raised the profile of decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health.     

The ethics of confidentiality: introduction

This essay aims to briefly summarise the collection of articles on confidentiality issues in psychology, and to highlight apparently conflicting opinions about the confidentiality rule. Conflicts are then analysed in terms of competing systems of ethics. Finally, the role for ethics education in psychology education and training is considered.     

Bioethics committee in the university teaching hospital in Bordeaux

Set up in 2011, the ethics committee at the teaching hospital in Bordeaux, although it is now obsolete in its organisation because of the "standardisation" in early 2012 of regional ethics groups, was nevertheless an original structure which deserves to be analysed for several reasons. First of all, why have a hospital ethics committee? Then, to do what? Finally, it is interesting to give a few indications about the working of this committee.     

Confronting Condescending Ethics: How Community-Based Research Challenges Traditional Approaches to Consent, Confidentiality, and Capacity

Community based research is conducted by, for, and with the participation of community members, and aims to ensure that knowledge contributes to making a concrete and constructive difference in the world (The Loka Institute 2002). Yet decisions about research ethics are often controlled outside the research community itself. In this analysis we grapple with the imposition of a community confidentiality clause and the implications it had for consent, confidentiality, and capacity in a province-wide community based research project. Through untangling these implications we provide recommendations for reframing how to think about research ethics and strategies for enabling research ethics’ processes to be more responsive to and respectful of community-based research.     

Protecting confidentiality rights: the need for an ethical practice model

All psychologists must uphold the same ethical standards about confidentiality even though each state imposes different legal limits on their ability to protect clients' confidences. The resulting ethical-legal confusion is exacerbated by legally based confidentiality training that treats legal exceptions as if they were the rule and fosters the impression that attorneys are now the only real experts about this aspect of practice. This article provides an ethics-based confidentiality practice model that clarifies the ethical rule and puts its legal exceptions into ethical perspective. Like the Confidentiality section of the American Psychological Association's (2002) Ethical Principles of Psychologists and Code of Conduct, this outline would apply to all psychologists regardless of state laws, but the details of its implementation would vary according to role and setting. It can be used as a universal training outline, a consultation and supervision tool, a guide to professional practice, and a basis for clearer ongoing conversation about the ethics of "conditional confidentiality." Psychologists can use this practice model to regain their status as experts about the confidentiality ethics of their own profession.     

Strict Confidentiality: An Alternative to Pre’s “Limited Confidentiality” Doctrine

In “Advisory Opinion on Confidentiality, Its Limits and Duties to Others” the Canadian Interagency Advisory Panel on Research Ethics (PRE) articulates a rationale for a priori limitations to research confidentiality, based largely on putative legal duties to violate confidentiality in certain circumstances. We argue that PRE promotes a “Law of the Land” doctrine of research ethics that is but one approach to resolving potential conflicts between law and research ethics. PRE emphasises risks that have never materialized, and ignores jurisprudence on challenges to research confidentiality. When we examine what the courts have actually done with research-based claims of privilege, we find they clearly recognize and affirm researchers’ ethical obligations to maintain strict confidentiality and protect research participants. Ironically, the one exception – where the court ordered that information be disclosed – occurred precisely because the researchers had limited confidentiality. The passive approach PRE espouses leaves vital questions about what protecting confidentiality to the “full extent possible in law” means, and leaves the impression that academics should accept whatever limitations the courts may impose without participating in the courtroom dialogue determining where those limits are drawn. In contrast, we believe confidentiality is so important to the protection of research participants and the integrity of the research enterprise that it is worth fighting for. The “ethics-first” doctrine of “strict confidentiality” we describe adheres to the social sciences’ and humanities’ longstanding commitment to research confidentiality and duty to the research participant.     

Cultural considerations in release of information

In most mental health professions, confidentiality is probably the most important ethical principle in psychology, aside from nonmalfeasance. However, confidentiality is embedded in the Western values of individuality and autonomy. This creates a moral and ethical dilemma for clinicians working with clients from other cultures. This article presents 3 cases to highlight the conflict that many clinicians are likely to face with regard to confidentiality when working with clients from South Asia and similar cultures. The importance of understanding how cultural values may contradict professional ethics and some ways in which the clinician can address them are also discussed.     

Cultural Considerations in Release of Information

In most mental health professions, confidentiality is probably the most important ethical principle in psychology, aside from nonmalfeasance. However, confidentiality is embedded in the Western values of individuality and autonomy. This creates a moral and ethical dilemma for clinicians working with clients from other cultures. This article presents 3 cases to highlight the conflict that many clinicians are likely to face with regard to confidentiality when working with clients from South Asia and similar cultures. The importance of understanding how cultural values may contradict professional ethics and some ways in which the clinician can address them are also discussed.     

Consulting the Many and the Wise

Conceived as a solution to clinical dilemmas, and now required by organizations for hospital accreditation, ethics committees have been subject only to small-scale studies. The wide use of ethics committees and the diverse roles they play compel study. In 1999 the University of Pennsylvania Ethics Committee Research Group (ECRG) completed the first national survey of the presence, composition, and activities of U.S. healthcare ethics committees (HECs). Ethics committees are relatively young, on average seven years in operation. Eighty-six percent of ethics committees report that they play a role in ongoing clinical decision making through clinical ethics consultation. All are engaged in developing institutional clinical policy. Although 4.5% of HECs write policy on managed care, 50% of HEC chairs feel inadequately prepared to address managed care. The power and activity of ethics committees parallels the composition of those committees and the relationship of members to their institutions. The role of ethics committees across the nation in making policies about clinical care is greater than was known, and ethics committees will likely continue to play an important role in the debate and resolution of clinical cases and clinical policies.     

A national study of ethics committees

Conceived as a solution to clinical dilemmas, and now required by organizations for hospital accreditation, ethics committees have been subject only to small-scale studies. The wide use of ethics committees and the diverse roles they have played compel study. In 1999 the University of Pennsylvania Ethics Committee Research Group (ECRG) completed the first national survey of the presence, composition, and activities of U.S. healthcare ethics committees (HECs). Ethics committees are relatively young, on average seven years in operation. Eighty-six percent of ethics committees report that they played a role in ongoing clinical decision making through clinical ethics consultation. All are engaged in developing institutional clinical policy. Although 4.5% of HECs write policy on managed care, 50% of HEC chairs feel inadequately prepared to address managed care. The power and activity of ethics committees parallels the composition of those committees and the relationship of members to their institutions. The role of ethics committees across the nation in making policies about clinical care is greater than was known, and ethics committees will likely continue to play an important role in the debate and resolution of clinical cases and clinical policies.     

Oral History and Ethical Practice: Towards Effective Policies and Procedures

This article examines how Canadian ethics policies affects historians who use oral history, and focuses on privacy and confidentiality, free and informed consent, and research involving Aboriginal peoples. The article concludes with recommendations for developing ethics policies that accord with historical methodology.     

Research Ethics Board (REB) Members’ Preparation for,and Perceived Knowledge of Research Ethics

The Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS) was first developed to establish a standard of practice in research ethics by the three federal agencies responsible for funding institutional research in Canada: Canadian Institutes of Health Research (CIHR), Natural Sciences and Engineering Research Council (NSERC), and Social Sciences and Humanities Research Council (SSHRC). In 2010, a second edition of the policy, known as the TCPS 2, was released with updated information and expanded coverage of research ethics issues. According to the TCPS 2, the Agencies’ mandate is “to promote research that is conducted according to the highest ethical standards,” and the TCPS 2 serves as a benchmark for this with respect for human dignity as its underlying value. Research institutions receiving Agency funding are to comply with this policy statement by forming Research Ethics Boards (REBs) to review all research involving human participants. The intention behind this review requirement is to provide a proportionate assessment of the benefit-to-risk ratio of the research, and in that process, to safeguard “respect for persons”, express a “concern for welfare”, and uphold “justice” (CIHR, SSHRC, NSERC 2010, p. 8). Research may not proceed until ethics approval is granted by an institution’s REB. The current study evaluates REB members’ perspectives on their knowledge of research ethics, and juxtaposes these perceptions with those of researchers. Specifically, we are interested in the extent to which REB members with less experience read the TCPS 2, and whether those with less experience have decreased confidence in their ethics knowledge.     

Ethical Issues in Tissue Banking for Research: A Brief Review of Existing Organizational Policies

Based on a general review of international, representative tissue banking policies that were described in the medical, ethics, and legal literature, this paper reviews the range of standards, both conceptually and in existing regulations, relevant to four main factors:(1) commercialization, (2) confidentiality, (3) informed consent, and (4) quality of research. These four factors were selected as reflective of some of the major ethical considerations that arise in the conduct of tissue banking research. The authors emphasize that any policy or ethical guidelines designed to regulate tissue bank research should address all four factors. Whenever this sort of research is conducted between several institutions or several countries, the paper suggests that the relevant entities work collaboratively to harmonize their standards.     

Confidentiality and privileged communication in group psychotherapy

The concept of confidentiality is fundamental to all forms of psychotherapy. The idea of protecting confidential material goes as far back as the Hippocratic Oath in ancient Greek history. Centuries later, authors continue to assert that "only by maintaining confidentiality can the essential groundwork of trust in treatment be developed" (Hough, 1992, p. 106). Others have even argued that without confidentiality, psychotherapy has no value (Epstein, Steingarten, Weinstein, & Nashel, 1977). Confidentiality in group psychotherapy is more complicated than in individual therapy because self-disclosure is at the core of group therapy and there are numerous people hearing the disclosures. Confidentiality in group therapy, once ignored in the literature on ethics, is gaining more attention as this modality becomes more widely practiced; so too is an acknowledgement that ethical dilemmas surrounding confidentiality in groups are commonplace. This article discusses the major considerations and dilemmas on confidentiality in group psychotherapy. We first review confidentiality broadly and discuss the ethical principles that are related to confidentiality. In the next section, we discuss the complexities of confidentiality in group psychotherapy. Finally, we review research on confidentiality in groups and describe common ethical dilemmas.     

Will the new code help researchers to be more ethical?

A code of ethics has 2 largely incompatible objectives: to set forth enforceable minimal standards of conduct and to teach about or invoke ethical conduct. The section of the new American Psychological Association code dealing with research ethics achieves the former to some degree. However, it neither provides needed education in the ethics of research nor states where the reader might turn for such information. The code is particularly deficient in the following areas: privacy and confidentiality; institutional review boards; deception; debriefing; data sharing; and research on marginal populations, on children and adolescents, and in organizational contexts. Suggestions are offered for providing a bibliographic resource, in hard copy and on-line, that would stimulate independent interest, scholarship, education, and research on research ethics.     

Confidentiality and paradox: the location of ethical space

Implicit in Jung's alchemical metaphor of the vas bene clausum is the idea of an analytic frame with a space inside it for something vital, a relationship between two selves, to develop. For this to happen, analysts must respect their patients' rights to confidentiality. The paper explores the analyst's state of mind and the intrapsychic processes that are constellated when struggling with ethical dilemmas about issues of confidentiality in analytic work. The author suggests that at times when analysts consider breaking confidentiality, there is often a disturbing inner conflict between their moral principles (codes of ethics) and their internal personal ethical attitude. At these difficult moments, the mutuality of the work and the vas bene clausum can be significantly disrupted. The analyst tries to find a third position, a mental and emotional ethical space where the subjective and the objective, the ethical and the unethical can become more companionable bedfellows.     

Confidentiality issues in psychological research

There has been increased attention in recent years to the importance of individual privacy and professional confidentiality both in Australia and overseas. At the same time, psychologists' growing research interests in areas such as AIDS, child sexual abuse, and domestic violence have led to new ethical dilemmas over the contract of confidentiality between researchers and their research participants. The present paper discusses a number of issues regarding the ethics of confidentiality in psychological research. Following Bok (1989), the issues are highlighted within the context of four ethical principles that underlie researchers' obligations to preserve confidentiality. These principles are derived from considerations of privacy, loyalty, the pledge of silence, and professional codes of ethical standards. Each of these principles is illustrated with examples taken from recent research. We devote special attention to instances that appear to provide a clash between moral principles.     

Facilitated Disclosure Versus Clinical Accommodation of Infidelity Secrets: An Early Pivot Point in Couple Therapy. Part 2: Therapy Ethics,Pragmatics, and Protocol

In couple therapy, one partner's private disclosure of infidelity presents a potentially polarizing issue involving the therapist's decision to facilitate disclosure or accommodate non-disclosure. Some therapists may assume accommodating an infidelity secret is the most compassionate and efficient option. We consider this decision in the context of therapy ethics of equal advocacy and confidentiality, implications for individual and relationship healing, and pragmatic aspects of conducting therapy. We conclude that measured disclosure of infidelity, determined by the aggrieved spouse, best resolves the potential collision of multilateral advocacy with confidentiality and offers the best prospects for a working therapy alliance and couple healing and renewal. A clinical protocol for facilitating disclosure of infidelity secrets is presented.     

Do authorship policies impact students' judgments of perceived wrongdoing?

Although authorship policies exist, researchers understand little about their impact on perceptions of authorship scenarios. Graduate students (N=277) at a large university read 1 of 3 vignettes about a graduate student-faculty collaboration. One half of the surveys included the American Psychological Association's statement on authorship. Participants rated (a) the ethics of the professor as first author and (b) the likelihood of a dissatisfied student reporting the authorship result, as well as the effectiveness and negative consequences of reporting. Work arrangements on the project had a consistent main effect. Also, an authorship policy impacted women's ratings of first authorship when the student contributed the idea for a project. For men, a policy impacted only ratings of the likelihood of reporting when a professor was first author on a student's dissertation. Apart from sex, no other demographic variables on participants were predictive. Discussion focuses on the policy's potential for making only some specific issues salient.