1. CONFIDENTIALITY
Where does the duty of confidentiality come from?
What does the duty of confidentiality require?
What kinds of disclosure are inappropriate?
When can confidentiality be breached?
What if a family member asks how the patient is doing?
Confidentiality is one of the core tenets of medical
practice. Yet daily physicians face challenges to this long-
standing obligation to keep all information between
physician and patient private.
Where does the duty of confidentiality come from?
Patients share personal information with physicians. You
have a duty as a physician to respect the patient's trust
and keep this information private. This requires the
physician to respect the patient's privacy by restricting
access of others to that information. Furthermore, creating
a trusting environment by respecting patient privacy can
encourage the patient to be as honest as possible during
the course of the visit.

2. What does the duty of confidentiality require?
The obligation of confidentiality both prohibits the
physician from disclosing information about the patient's
case to other interested parties and encourages the
physician to take precautions with the information to
ensure that only authorized access occurs. Yet the context
of medical practice does constrain the physician's
obligation to protect patient confidentiality. In the course
of caring for patients, you will find yourself exchanging
information about your patients with other physicians.
These discussions are often critical for patient care and
are an integral part of the learning experience in a
teaching hospital. As such, they are justifiable so long as
precautions are taken to limit the ability of others to hear
or see confidential information. Computerized patient
records pose new and unique challenges to confidentiality.
You should follow prescribed procedures for computer
access and security as an added measure to protect
patient information.
What kinds of disclosure are inappropriate?
Inappropriate disclosure of information can occur in
clinical settings. When pressed for time, the temptation to
discuss a case in the elevator may be great, but in that
setting it is very difficult to keep others from hearing the
information exchanges. Similarly, extra copies of handouts
from teaching conferences that contain identifiable

3. patients should be removed at the conclusion of the
session. The patient's right to privacy is not being
respected in these sorts of cases.
When can confidentiality be breached?
Confidentiality is not an absolute obligation. Situations
arise where the harm in maintaining confidentiality is
greater than the harm brought about by disclosing
confidential information. In general, two such situations
that may give rise to exceptions exist. In each situation,
you should ask - will lack of this specific information about
this patient put a specific person you can identify at high
risk of serious harm? Legal regulations exist that both
protect and limit your patient's right to privacy, noting
specific exceptions to that right. These exceptions follow.
Exception 1:
Concern for the safety of other specific persons
On the one hand, the 1974 Federal Privacy Act restricts
access to medical information and records. On the other,
clinicians have a duty to protect identifiable individuals
from any serious threat of harm if they have information
that could prevent the harm. As mentioned above, the
determining factor in justifying breaking confidentiality is
whether there is good reason to believe specific
individuals (or groups) are placed in serious danger
depending on the medical information at hand. The most

4. famous case of this sort of exception is that of homicidal
ideation, when the patient shares a specific plan with a
physician or psychotherapist to harm a particular
individual. The court has required that traditional patient
confidentiality be breached in these sorts of cases.
Exception 2:
Concern for public welfare
In the most clear cut cases of limited confidentiality, you
are required by state law to report certain
communicable/infectious diseases to the public health
authorities. In these cases, the duty to protect public
health outweighs the duty to maintain a patient's
confidence. From a legal perspective, the State has an
interest in protecting public health that outweighs
individual liberties in certain cases. In particular,
reportable diseases in Washington State include (but are
not limited to): AIDS and Class IV HIV, hepatitis A and B,
measles, rabies, tetanus, and tuberculosis. Suspected
cases of child, dependent adult, and elder abuse are
reportable, as are gunshot wounds. Local municipal code
and institutional policies can vary regarding what is
reportable and standards of evidence required. It is best
to clarify institutional policy when arriving at a new site.

5. What if a family member asks how the patient is
doing?
While there may be cases where the physician feels
compelled to share information regarding the patient's
health and prognosis with, for instance, the patient's
inquiring spouse, without explicit permission from the
patient it is generally unjustifiable to do so. Except in
cases where the spouse is at specific risk of harm directly
related to the diagnosis, it remains the patient's, rather
than the physician's, obligation to inform the spouse.