A female patient presents to the Emergency Department (ED) with a left arm fracture reportedly due to a fall, but privately shares with you, the physician assistant, that the fracture is actually due to intimate partner violence (Jenkin & Millward, 2006). The patient reports she was thrown down the stairs following a fierce argument with her husband, which was heard by her two children. Both the patient and her husband are known to the staff at the ED, the husband being a healthcare professional who had undertaken training at the ED. It is determined the patient had no loss of consciousness following the incident and she is alert and oriented to person, place, and time. She complains of right-sided chest pain with inspiration but refuses physical examination. The patient asks that you neither document nor inform the attending physician of the true cause of the injury. The patient’s request prompts the question: ethically, should we respect the patient’s decision for non disclosure, both verbally and through documentation in her chart?
We will answer this question using the principles of patient autonomy and confidentiality. First we seek to briefly define these principles. The principle of autonomy is described by Yeo et al as “the right to make independent decisions concerning one’s own life and well being” (2010). Autonomy can be subdivided into four key elements: free action, effective deliberation, authenticity, and moral reflection (Yeo et al 2010). In this case, we will examine the element of free action, meaning the patient should be able to do what she wants to do, and the element of effective deliberation, meaning the patient’s ability to make a rational decision without impairment. The second principle that will be used is the principle of confidentiality. This principle, according to Dr. Timothy W. Kirk, serves to strengthen the “trust and confidence between patients and their health care providers” (2015). Dr. Kirk describes three justifications to maintain confidentiality, and they are; “respect for persons, avoiding preventable harm, and optimizing clinical outcomes” (2015).
We argue that given the facts of the case, one should not disclose the intimate partner violence without consent from the patient. This decision for nondisclosure is upheld by the principles of autonomy and confidentiality. First, the patient is completely alert and oriented and she voluntarily shares of her incident in a private environment (the plaster room) with only you. Presumably you are not perceived as a threat to her and you in fact made the patient feel comfortable enough to be honest about the cause of her injury. She voluntarily chose to tell you how her elbow injury actually occurred, when she could have continued to cover them up along with her husband’s terrible actions (free action). The patient is capable of deliberation and is able to do whatever she desires in this scenario. There is no indication provided that there is anything inhibiting or influencing her thought process. Furthermore, she alone understands the full extent of her situation better than anyone else. Thus she is the best assessor of the consequences of disclosure versus nondisclosure (effective deliberation). In this case, respecting her autonomy supports nondisclosure.
Being a moral person is impart due to the right to exercise discretion over what aspects of ourselves to make public and what aspects to keep private (Kirk 2015). The patient’s husband is known to the staff of the ED and disclosure might have an effect that the clinician might never personally experience but the patient will certainly experience more intensely. One could argue that if you over step boundaries by disclosing and assume that you know better than the patient, you are harming the patient and are making her feel inferior, in the same way that her husband makes her feel. In this way, violating confidentiality is a threat to the patient’s personhood by interrupting the integrity of her life (Kirk 2015). By not disclosing the true cause of her injury, you are recognizing there may be very little she has control over in her life, and her request is the one thing she can control. There are predictable benefits to maintaining confidentiality, at the forefront is the trust the patient has placed between you two. With the patient knowing you’ve honored her request, it is increasingly likely she will maintain trust in the health care system, fostering future disclosure and better health outcomes. As the only person entrusted with this information, you have a unique opportunity to share resources and offer support to the patient on her terms. In light of the principles of autonomy and confidentiality, you are ethically obligated to respect the patient’s request for nondisclosure.
A strong counter argument then becomes the following: are we actually preventing harm by returning the patient to an abusive situation? With this mode of thought, violating the patient’s trust could be justified. It could lead to further physical examination, offer mental health resources, and support from social workers. However, in order to maximize on these benefits the patient would have to agree to all of these services. The patient did not sustain any loss of consciousness and is completely alert and oriented. Therefore we can assume that there is no inhibition in her decision making capacity. Disclosing could also dissuade her from being honest about the cause of her possible future injuries. Obtaining such information from the patient would be difficult after breaking her trust.
Based on the principles of autonomy and confidentiality, we recommend that you honor the patient’s request not to disclose her intimate partner violence to the attending physician and not document it in her chart. Since you are the physician assistant who was confided in, you’ve been trusted to maintain confidentiality and you can utilize this trust to provide education and support to the best of your ability. Trust would be absent had you chosen to disclose. By maintaining confidentiality, you allow maximization of benefits for the patient and minimize perceived harms the patient might experience. With the undeniable risks associated with disclosing and not disclosing, autonomy takes precedence. It is paternalistic to think that you can override the patient’s request for nondisclosure. In this case, the patient’s request is the authority, and she alone knows the extent of her full story. Based on the principles of patient autonomy and confidentiality, we recommend the physician assistant not disclose the true cause of injury to the attending nor document it in the patient’s chart.
Works Cited
- Jenkin, A, Millward, J. (2006). A moral dilemma in the emergency room: Confidentiality and domestic violence . Accident and Emergency Nursing, 14(1), 38-42.
- Kirk, TW. (2015). Confidentiality . In N Cherny, M Fallon, S Kaasa, R Portenoy, & D Currow (eds.). Oxford Textbook of Palliative Medicine. (5th ed.) New York/London: Oxford University Press, pp. 279-284.
- Yeo, Michael et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
