Biomedical ethics week 4 reading and module PDF

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Biomedical ethics week # 4 Read: BE 3, BE 3 (Kipnis, Unger), WP Chapter 4 - "Exegetical and Expository Writing" Biomed 3 Therapeutic privilege - The idea that a medical professional may deceive or withhold the truth from a patient with providing the truth will produ...

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Biomedical ethics week # 4 Read: BE 3.1, BE 3.3 (Kipnis, Unger), WP Chapter 4 - "Exegetical and Expository Writing" Biomed 3.1 Therapeutic privilege - The idea that a medical professional may deceive or withhold the truth from a patient with providing the truth will produce harm - Another view sees the medical professional as someone who has skills and judgement but needs to make full disclosure to patient o Essential for patient to make informed decision Lying and withholding truth - 2 ways of deceiving- lying or withholding the truth the ethics of lying - Kant says it is always wrong to lie to anyone about anything, no matter the consequences of ultimate goal of deception Access to medical records - Many good reasons to allow patients access to their own records Confidentiality- the duty of confidentiality - The duty of confidentiality means that a physician cannot reveal any medical info about their patients to others without the patients consent - Exceptions of the duty: o Not absolute o Needs to be passed on when others are in danger o Possibilities:  Unqualified confidentiality: patients should understand that no info about them obtained during treatment will be passed on to anyone else under any circumstances without patients consent  Qualified confidentiality: patients should understand that some info about their treatment will be passed on to others under some circumstances without their consent (for not harming others, for law, or for benefiting public)

Big data - Another confidentiality issue- if medical info is stored in a way that can be made easily available for “secondary uses”, aka anything not benefiting patient o Ex medical research, health stats

o These are forbidden without patients consent, unless there are no patient identifiers Genetic info- 2 examples of genetic tests that provide medically relevant info: o 1. BRCA Test- test analyses blood dna to identify harmful changes in either gene BRCA 1 or 2 o 2. The huntington disease test- using blood sample, test analyzes DNA to identify harmful numbers of CAG repeats in parts of the huntington gene - genetic exceptionalism: the view that genetic info is a special type of medical info and must be treated with greater care than other health info - Murray says there is no reason to give genetic med info any special legal protections Biomed 3.3 – confidentiality of information Kenneth Kipinis The case of the infected spouse - husband is positive for AIDS, not sure if he is gonna tell ex wife - law: o obligation of confidentiality will give way when a doctor is aware that a patient will seriously injure someone o special legal duties: can apply to individuals occupying certain roles- a parent has a special duty to rescue a drowning daughter, firefighters to take occupational risks o general legal duties: pay taxes, respect others property etc o ethical obligations can conflict with legal ones - personal morality: o morality is a set of beliefs about obligations o professionalism can require that one set aside personal morality – ex if jahovas witness doc needs to give blood transfusion - personal values: o values help explain personal conduct o don’t appeal to personal values to inquire about what physicians in general should do o key part of professionalism is putting values aside

the concept of professional obligation - personal values bs core professional values o preference for almonds is personal, preference for confidentiality is a value all doctors need to posses

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physician should be ready to put aside personal values, put aside what the legal system wants them to care about, and think about what the responsible physician should do core professional values: trustworthiness, beneficence, respect for autonomy ethical problems can arise… o first, when core values appear to be in conflict o second, when it is unclear what some core professional value requires one to do to establish professional obligation… o attention to core values needs to be part of professional education o core values aren’t just goods that doctors care about, they are goods that we want our docs to care about o exclusive social reliance upon the profession as means by which certain matters are to receive attention in summary- the medical profession has ethical obligations bc of its public commitment to secure social values and bc of our reliance on the profession

the duty to diminish third parties - each doc is ethically required to do what a responsible doc will do o question: how do you know? - Back to the infected spouce example, either need to explain why you broke confidentiality or explain why you didn’t disclose important info to wife - The bad outcomes of not disclosing outweigh losing the mans trust a defense of unqualified confidentiality - Doc should let patient know that in these circumstances- I will need to breach confidentiality - This may make a patient not disclose info to doc - Strategies cant be used if the fear of reporting deters patients from disclosure - Answer- when couple first enters office- say that if one were to be infected- I will do everything to protect endangered partner except for violating confidentiality o If wife understands from the beginning that confidentiality wont be breacued,s he will understand she has final control over her choices - Need to try to persuade man to disclose to wife- say wives will find out eventually, more severe later on Concluding remarks - An inability to risk killing patients can disqualify one for the practice of medicine - The tak of professional ethics in medicine is to set out principles that will allow the profession to discharge its collective responsibility’s to patients and society - Confidentiality is shown to be effective in making therapeutic alliances, brings better outcomes and most likely to prevent serious harm to majority - Docs may feel guilty about foreseeable consequences of actions and inactions- but shouldn’t be bc they are doing what a good doc should do

Breaching confidentiality Dave Unger -

Confidentiality is the concept that med info can be kept save and revealed only to authorized persons Sometimes necessary to breech confidentiality

1. Reporting and notification - Ex child abuse - Parent patriae- legal instrument by which the state can become the parent when a real parent is neglecting - Mandatory in Canada to report abuse - 3 times when confidentiality can be breached to protect members of public: o duty to report impaired physicians and physicians suspected of sexual assault o duty to report unfit drivers or impaired drivers -

-communicable diseases- mandatory to report diseases that pose threat to public o patients have no choice so confidentiality is waived o physicians need to tell patients this before testing is ordered o sometimes people don’t want to be tested for HIV to avoid stigma

2. disclosing and warning - physician needs to disclose if they have anything – ex hiv - duty person has to report their hiv to sexual partners 3. duty to warn - harm principle says that individual rights must give way when there are risks of harm to others - obligation to report hiv, and obligation for officers to attempt contact tracing - no law in Canada about duty to warn - before diagnosis made, can have genetic counselling which makes an action plan, once diagnosis is made, physicians first ask diagnosed patient to disclose on their own, if they wont, physician should try to gain consent of the index case before disclosing to family members - duty to warn means an obligation of the HCP to warn a third party of danger from a patient of that HCP - duty to protect goes beyond duty to warn and includes te duty to protect a third partyincluding actions performed on a threatening patient such as holding against their will - law doesn’t require HCP to breech confidentiality but rather permits them to do so -

physician must warn if a patient threatens3rd party with harm and if its likely to be carried out

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if a threat is likely and imminent, and if the potential for serious harm is great, caregivers should warn law enforcement

How should health data be used? Bonnie Kaplan -

electronic health care records ring concerns over confidentiality

what’s special about health data? International principles - what is private, stigmatizing etc varies for different cultural groups fair information practices and de-identification - The Fair information practices underpin privacy policies in European Union and USAboth protect personal data differently - Both usa and EU construe privacy as control and protection of data rather than other conceptions of privacy - Didn’t read this well Duty of confidentiality - Clinicians duty to patients includes maintaining confidentiality - Violating conf could inhibit patients from confiding in them - Private data cant be passed to 3rd party without permission Patient benefits and harms - Patients benefit from having record info available bc physician can better understand history - Patients can be harmed when data about them is used to violate privacy o People change behaviour to withhold info to protect their health information

Transparency and consent - More thought is needed concerning which data uses are acceptable and what control ind should have about data about themselves - Principles of data collection- transparency, legitimanty, and proportionality- specify that the person from whom data obtained should be informed about what will be done with the info - Patients privacy concerns are when they don’t know what is being done with their data Who benefits - Clinical data include data that patients are required to provide to receive care - It is a cost of healthcare to collect and store patient records o People pay directly or indirectly through insurance - Secondary use and big data analytics are affected by the costs of collecting, storing and organizing data

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To reduce costs, health data processing is outsourced from countries with stronger privacy protection Confusing

Health data uses: big data, data minding, research and biosurvielliance - Electronic health records and health info networks provide a wealth of data for public health, health improvements and research - Data can be used for range of beneficial purposes - Harms- patients may withhold sensitive info that they fear will be used against them Who sells and uses data? One mans bread is another mans poison - Strong privacy could affect the globalized industry and innovation and trade - Medical info for identity theft is selling for lots of money - Many may benefit from data sales - If sales were constricted, some fear data wouldn’t be collected and would compromise research and new drug development - If health data were unrestricted- animal right activist could buy info about researchers vet purchases o So depending on many factors, info could threaten safety and have adverse effects Ownership, commodification and de contextualization - Right to sell data is muddies by lack of clarity over the legalities of data ownership - Law in USA doesn’t say clearly who the owner should be - Well known electronic health record vendors have sold de-identified copies of databases to pharmaceutical companies etc Conclusions - Widespread use of electronic patient record systems enables opportonies to improve health care through data sharing, secondary use and big data analytics - But widespread use of electronic records creates more opp for privacy violations - Ethical and policy analysis related to health data should consider vbenefits and harms - Public is concerned due to lack of transparency about data use - Using data collected for one purpose for another can undermine public confidence especially if the are unaware of the reuse - Look back at Source and Sorrelle court cases WP Chapter 4 - "Exegetical and Expository Writing" Exegetical and expository writing - An exegesis ia s interpretation or analysis of a written work - An exposition is a description or explanation of a philosophical position, theory or idea - Writing an exegetical or expository essay involves defending your position Rule 1: Be charitable when characterizing the views of others - Before starting, need to read what you are going to interpret, analyze or explain

Rule 2: provide evidence that your interpretation is correct - Use quotations Rule 3: use quotations judiciously - Sometimes paraphrase Rule 4: draw on context - Can use alternatives and then give reasons for rejecting Rule 5: state why the issue matters

Module Guided Reading: "A Defense of Unqualified Medical Confidentiality" by Kipnis The duty of confidentiality is important in medical ethics. Generally speaking, physicians shouldn't disclose a patient's medical information to third parties without the patient's consent. However, most bioethicists and medical professionals agree that, under some circumstances, it's appropriate to disclose information without consent. One such widely agreed upon circumstance is when disclosing information is necessary to prevent others from being significantly harmed. For example, if a psychiatrist has good reason to believe that her patient is likely to commit murder in the near future, then it's arguably appropriate for her to inform the police of her worries, even if doing so requires disclosing information that her patient provided in confidence. Legal cases of this sort include Tarasoff v. Regents of the University of California and Smith v. Jones. In his article, Kipnis defends a radical position not shared by many physicians or bioethicists. According to Kipnis, physicians' duty of confidentiality should never be broken, even in circumstances like the above. To illustrate the issue he's discussing, Kipnis describes 'The Case of the Infected Spouse.' Though most of us would agree that the physician should inform Wilma that her husband has AIDS, Kipnis maintains that this is the wrong conclusion to draw. Before getting into his argument, Kipnis distinguishes professional obligations from other sorts of obligations, e.g., from legal obligations and from personal moral obligations. He's careful to note that the duty of confidentiality is specifically a professional obligation. 

Why do you think he bothered to do this? What it is about the idea of a professional obligation that's important to his argument? Kipnis's main argument is expressed on pages 124-125. Though cases like 'The Case of the Infected Spouse' seem to involve a conflict between professional values, Kipnis argues that this conflict is actually an illusion.

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What are the professional values that appear to be in conflict? And why does Kipnis think the conflict is merely apparent?

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What are the premises in Kipnis's arguments? Can you think of any problems with that argument?

Guided Reading: "Breaching Confidentiality" by Unger Unger provides the reader with information about the different circumstances where, in Canada, it is standard to report medical information to third parties. By and large, the purpose of Unger's article is to be informative, rather than to present a philosophical argument. In that respect, it's different from most of the articles we read in this course. That said, one thing Unger's trying to do is impress upon the reader the surprisingly large number of circumstances where sharing information without patient consent is standard practice. When reading Unger's article (particularly the third section of it), it will be helpful to keep the following questions in mind: 1. In the section entitled "Duty to Warn", Unger distinguishes warning from other cases of reporting. What does Unger think is distinctive about warning? What are some cases of reporting that aren't also cases of warning?

2. How is a duty to warn different from a duty to protect?

3. According to Unger, some patient advocates have argued that the existing case law only permits breaching confidence for the sake of warning: it doesn't require warning. From a moral perspective, do you think the distinction between permitting and requiring is important? Are doctors morally required to break confidence in order warn third parties, or is it merely morally permissible to break confidence? Or is warning not even permissible?

4. Assuming that doctors sometimes have a duty to warn, what are the circumstances under which they have that duty? What factors are relevant to determining when the duty to warn is present?...