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Privacy and Confidentiality in the Therapeutic Relationship

Section 8
Desire to Die

Question 8 | Test | Table of Contents

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The correct answer is C. Your client has the right to have this information kept confidential. C states inform your client of her options.

A, urge your client to leave her husband, is incorrect because, even though this may be one good option for your client, it may also put her at risk, and she may not be ready to make such a move.

B, work with the client to document the frequency, magnitude, and duration, is incorrect because your client has more pressing issues of self-protection. Answer B describes the taking of baseline measures for marking future progress in behavior modification therapy, and this is obviously a low priority right now.

D, interview the husband, is incorrect because this course of action will reveal to the husband that your client has informed you of his behavior. She had indicated that this might pose a threat for her. This course of action is very likely to be ineffective and actually to cause some violent behavior on the husband's part.

Let us look at some of the medical confidentiality gray areas...Legal Action Involving Breaches of Patient Confidentiality. This is a partial list of a few selected lawsuits in which patients alleged breaches of confidentiality.

Legal Action Involving Breaches of Patient Confidentiality
Estate of Behringer v. Princeton Medical Center
, 249 N.J.Super. 597 (1991). Behringer, a surgeon at Princeton Medical Center, was diagnosed with AIDS. Behringer's chart, which included several references to the diagnosis, was kept at the nurses station on his floor with no special protection; His condition soon became widely known. Behringer sued the hospital for its failure to take reasonable steps to protect his confidentiality.

Velazquez v. St. Clare's Hospital, (Kings County Supreme Court, New York, 1994). Velazquez was admitted to St. Clare's Hospital in 1991. In 1992, while she was running for election to U.S. House of Representatives, copies of her medical records were distributed to the press, which reported on them. Velazquez sued the hospital for breach of contractual and fiduciary duties of confidentiality, for wrongful disclosure, and for negligence in maintenance of the security of the medical record.

Doe v. Methodist Hospital, (Hancock County Superior Court, Indiana, 1992). According to the complaint, Doe, who had tested positive for HIV, disclosed his HIV status to paramedics when he was taken to the hospital after a heart attack. The paramedics noted his status on their report, which became part of Doe's medical file. Hospital employees revealed Doe's HIV status to his coworkers, and Doe sued the hospital and some of its employees for invasion of privacy and other wrongful conduct.

O'Connor v. Rutland Medical Center, (Vermont, 1994). O'Connor claimed that on two occasions different hospital employees discussed her medical condition, without her consent, with her husband and ex-husband, and she sued.

So the ethics audit question here is, what is your confidentiality policy in discussing information with family members, relatives, and significant others?

Ethics and a Burn Victim's Desire to Die
In July of 1973 an unmarried 26 year-old-man, whom we shall call James, was severely burned when he and his father set off an explosion from a leaky propane gas pipeline. The father died before reaching the hospital, and James sustained second and third degree burns over two-thirds of his body. He is now blind in both eyes, although he might possibly be able to recover sight in one eye.

After nine months of treatment, the tips of his fingers have been amputated, his hands are useless, he cannot get out of bed by himself, and the burns are still not healed. In order to keep the open burns from becoming infected, James must be immersed daily in a bath of antiseptic solution. The baths are preceded by injections that make James unconscious, but the dressing of the burns after his bath is still quite painful to him.

James is an intelligent and articulate young man. He has persistently pleaded to be allowed to leave the hospital and go home to die. He says that he will not wait to die a natural death from the infection that would begin in the open burns but would take measures to end his own life. He has recently refused permission for further surgery on his hands.

The physicians have called in a consulting psychiatrist with the intent to have him declared incompetent, but the psychiatrist has concluded that James is rational. James' argument for wanting to end his life is that he has been an active person, has participated in sports, and is fond of the outdoors. He does not find enough value in living blind and as a cripple to make it worthwhile to endure the painful treatments and the problems of adjusting to a new lifestyle. James has asked the physician to help him get out of the hospital, so he can go home and die.

Should the physician honor James' request? Let's apply the concepts discussed in this chapter.

♦ I. Factual Issues
The physician must answer a number of factual questions before he can make a decision. One of the questions is whether James could adjust to his new lifestyle. James says he would never find life worth living as a disabled person, but the physician has access to histories of other victims of catastrophes and will want to make a determination on his own of James' prospects for future happiness. The physician will also want to know the law governing these situations.

What can he do legally without incurring unacceptable liabilities for himself or the hospital? You may think of other factual issues that are important in the case.

II. Conceptual Issues
Two important conceptual issues arise in the case. The first is whether this proposed action is a case of suicide. Because James wants to end his life by some direct means and out of concern for his own well-being, most people would consider his action to be suicide. The second question, which is more difficult, has to do with the concept of rationality. Is James rational enough to make such a serious decision about his own future?

The physician has to have a clear concept of what he means by rationality before he can answer this question. Of course, factual issues can be raised here as well. The physician might have a clear concept of what it means to act rationally but might still be puzzled about whether James is acting rationally. If he defines rationality as involving, among other things, making decisions on the grounds of all available evidence, he might still wonder whether James fully understands the degree to which he will be able to manage his own affairs at home. Nevertheless, having a clear concept of rationality is an important first step in determining whether James is rational.

III. Moral Issues
This case has two important moral issues. One is the morality of killing oneself. This question is especially interesting, because James is not dying. Given sufficient time, the burns will heal, and James will be sent home. He should be able to live out his normal lifespan, even though he will be handicapped.

The second issue has to do with the obligations and prerogatives of the physician. Does the physician have an obligation to help James get out of the hospital? Does he have an obligation to help James end his life if he is asked to assist? Does he have the right to try to keep James in the hospital if he thinks James is not rational? Does he have the right to try to keep James in the hospital if he disagrees with James's decision to end his life, even if he believes James is rational?

IV. Moral and Factual Statements
Recall that moral conclusions do not follow directly from the facts of the case. For example, the fact that James will recover and can eventually be sent home does not necessarily mean that his ending his life would be wrong, although this consideration is relevant to the issue.

The fact that the physician is prevented by law from directly administering a lethal injection to James at his request does not settle the question of whether he should legally be allowed to do so. The fact that the physician may be opposed to all forms of suicide does not necessarily mean that he should act to prevent James from killing himself.

V. Characteristics of Moral Statements
The moral questions at stake seem to exhibit the four characteristics of moral statements.

, the answers given to the moral questions at issue prescribe the conduct that James and his physician should follow. The statement that it is wrong for James to commit suicide implies that James should not take any measures to end his own life. The conclusion that the physician has an obligation to help James get out of the hospital implies that he should take steps to achieve the goal.

Second, the moral statements made about this case are ordinarily made from an impersonal standpoint. If we are making judgments about the case from an observer's perspective, this impersonal standpoint can be assumed. But, even if we take the physician's standpoint, we would presumably ask what should be done based on his moral and professional obligation. Self-interest is not a legitimate consideration unless it would apply to any other physician in the same situation. If injecting James with a lethal drug would result in the physician's incarceration, that consideration would appropriately carry some moral weight. But, it would carry moral weight with any other physician in the same situation.

Third, the moral issues have a serious and overriding importance. The moral issues are more important than issues of medical etiquette or the aesthetic questions regarding James's burns. They are even more important than the legal issues in the case, because we might conclude that the laws should be changed to accommodate our moral beliefs about what should be done.

Fourth, the issues cannot be settled merely by an appeal to authority or to consensus or tradition. Deciding whether it is wrong for James to take his life or whether the physician should help him take his life involves more than taking a vote or determining how the issue would have been decided in the past.

VI. Concepts in Moral Philosophy
We can look at this problem from either a consequentialist or a non-consequentialist perspective.
An egoist would ask about the consequences of the alternatives for James' or the physician's self-interest. A utilitarian would ask about the consequences for the general human welfare. Non-consequentialists, such as natural-law theorists and advocates of the ethics of respect for persons, would approach the issues differently. They would ask whether James' or his physician's actions were in accordance with human nature or the respect due the person.

We shall leave the steps of this determination for another time; the important point is that the consequences of alternative actions are not the decisive point. For example, by the standards of natural law, James should not kill himself, even if the remainder of his life produces no benefit for him or anyone else.

Finally, in a discussion of the case, we would use the terms good or bad, intending thereby to commend or condemn the actions, motives, or people involved. We would also refer to the actions of the people involved as right or wrong, intending thereby to classify them as morally obligatory (permissible) or as morally impermissible. The concepts and distinctions we have discussed in this first chapter, then, are an essential part of our moral discourse.

- Gellman, R., PhD. (1999). The Myth of Patient Confidentiality. Information Impacts Magazine.

Peer-Reviewed Journal Article References:
Harrison, D. P., Stritzke, W. G. K., Fay, N., Ellison, T. M., & Hudaib, A.-R. (2014). Probing the implicit suicidal mind: Does the Death/Suicide Implicit Association Test reveal a desire to die, or a diminished desire to live? Psychological Assessment, 26(3), 831–840.

Joo, J., Hwang, S., & Gallo, J. J. (2016). Death ideation and suicidal ideation in a community sample who do not meet criteria for major depression. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 37(2), 161–165.

Kolva, E., Rosenfeld, B., Liu, Y., Pessin, H., & Breitbart, W. (2017). Using item response theory (IRT) to reduce patient burden when assessing desire for hastened death. Psychological Assessment, 29(3), 349–353.

Mimran, M. (2020). Review of flirting with death: Psychoanalysts consider mortality [Review of the book Flirting with death: Psychoanalysts consider mortality, by C. Masur, Eds.]. Psychoanalytic Psychology, 37(3), 259–261.

Rigg, T. (2018). The ethical considerations of storing client information online. Professional Psychology: Research and Practice, 49(5-6), 332–335.

Tipples, J. (2018). Caution follows fear: Evidence from hierarchical drift diffusion modelling. Emotion, 18(2), 237–247.

Here is a question that revisits the "Duty to Warn," for purposes of review. While in a therapy, Jill reveals that she is planning to physically harm another client whom she had met in a group you conduct. What is the best ethical course of action for the social worker?
a. first, the therapist should alert his/her supervisor
b. the therapist can do nothing because she/he is bound by client confidentiality
c. the therapist should first warn the other client
d. the therapist should first tell the police of her client's intentions to harm another client
To select and enter your answer go to Test.

Section 9
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