(a)

Intoduction

A breach in doctor-patient confidentiality can be defined in a few ways.

From a legal perspective, confidentiality relates to any bit of information
shared with an individual that cannot be divulged to a third party without
explicit consent from the owner of the information.

Doctor-patient confidentiality functions in the same way: Any details

exchanged during the course of treatment must, by law, stay within the
confines of doctor and patient unless the patient consents otherwise. If by
chance any information is shared by a physician to a third party without
authorization from the patient, a breach in doctor-patient confidentiality may
have been committed.

The following are the different ways in which confidentiality may not be absolutely
considered.

Risk of danger to the patient and others

An exception to the psychotherapist-patient privilege and confidentiality occurs in
circumstances when a patient is in such mental or emotional condition so as to be
dangerous to him/herself, others, or another's property only when such a disclosure is
necessary to prevent the threatened danger. For example, in situations where a patient
is threatening suicide and the therapist determines that informing a loved one of the
patient is necessary to keep the patient from doing him/herself harm.

Confidentiality and Conjoint Therapy - "No Secrets"

Therapists who treat couples should develop a policy with regard to information
shared with the therapist by one member of the couple outside of the presence of the
other member of the couple. Such a policy should state that such information might be
disclosed to the other member of the couple at the therapist's discretion. In other
words, the therapist will not allow him/herself to be put in the position of holding the
secrets of a patient participating in conjoint therapy. Each of the conjoint patients
should be informed of and agree to this policy. Too many therapists find themselves
practicing without such a policy, and then being asked, by a patient in conjoint
therapy, to keep a secret from the other person receiving treatment. Absent a "no
secrets" policy, the therapist may find him/herself in a situation where one member of
the couple tells the therapist in a private session that he/she is planning to leave
his/her partner despite the therapy. It would be unethical for a therapist with such
information to continue to work with the couple knowing that one of the patients is
not an honest and active participant of the treatment and has a contradictory agenda.
The therapist is also in a bind should he/she choose to terminate therapy because of
the information he/she has received. The therapist would have to provide a reason for
termination, leaving the unknowing member of the couple in the dark. "No secrets"
policies are an essential tool for anyone doing conjoint work.

Audit and secondary uses of confidential information

The public is not likely to be aware of the degree to which their information is transferred.
Medical research requires express consent to be sought. Audit is often undertaken under the
presumption of implied consent and is therefore acceptable if data are sufficiently
anonymized. Educational publications require signed consent except in exceptional
circumstances when a subject cannot be traced. Ideally, it is important for doctors to maintain
professional integrity by making efforts to gain express consent where applicable.

Confidentiality and Minors

Children may wish to withhold sensitive information from their parents. The mature minor's
right to confidentiality is permitted when it is deemed in their best interests (Gillick v Norfolk
and Wisbech Area HA [1986] AC 112). There does remain a duty on the doctor to persuade
the child to inform their parent or to allow the doctor to do so. If the doctor suspects the child
is at risk, they are required to report their concerns to the relevant authorities. This applies to
anaesthetists who may only be caring for the child during a short visit for surgery. The duty to
disclose is a fine balance whereby a missed case of child abuse can result in ongoing neglect
and potentially recrimination of the healthcare professionals involved, 8 but conversely, an ill-
founded accusation may cause substantial distress to the accused.

Making a disclosure with patient’s consent

This is the most common reason for revealing confidential details. If the patient expressly
consents to disclosure, a doctor is relieved from the duty of confidence. Consent may be explicit
or implied. Explicit consent requires active agreement but may be written or oral. It is the
preferred form as there is no doubt as to what has been agreed and is usually required for sharing
more sensitive data. The patient must have the necessary capacity to consent, that is, understand,
retain, and balance the information, and also communicate their decision. This can be challenging
in the critical care setting when patients are often sedated or suffering disease processes affecting
their conscious level.

Disclosures made with the patient's consent are in theory not breaches providing the
consent is fully informed and freely given. Patients should ideally disclose
information voluntarily or be informed of the disclosure beforehand, and where
practicable consent obtained.

Other disclosures may be justified on the presumption of implied consent, when

obtaining consent is undesirable or not possible, for example, a sedated patient on
intensive care unit (ICU). This may extend to Independent Mental Capacity
Advocates, Lasting Powers of Attorney, or deputies appointed by the courts for
decision-making on matters of healthcare. Any decision made on behalf of an
individual lacking capacity to disclose should be done so proportionately and in their
best interests

Mandated Exceptions to Confidentiality Other times therapists disclose certain

information because the law requires them to do so. The most common types of
mandated disclosures are making suspected child, elder, and dependent adult abuse
reports and responding to court orders. Consequently, disclosing certain information
because the disclosure is mandated by law is another good principle to pin a decision
to disclose information on. In fact, failing to make mandated disclosures of certain
information can result in greater legal trouble for therapists than making the
disclosure!

Access to Medical records

Limited information may be disclosed to solicitors or persons entitled to claims upon death
under the Access to Health Records Act 1990. The Medical Reports Act 1988 permits
individuals access to personal medical reports for employment or insurance purposes. The
Freedom of Information Act 2000 provides for disclosure of information held by public
authorities and is not intended to allow people to gain access to their personal information.
Public authorities are defined under the Act and includes any organization treating NHS
patients.

Disclosures and the Media

Public curiosity is not a justification to breach confidentiality and is generally considered
unacceptable. The Public Interest Disclosure Act 1998 authorizes such breaches in
confidence, referred to as ‘qualifying disclosures’, and offers protection to ‘whistleblowers’
who report wrongful or illegal activity. Such disclosures are permitted if the employee
reasonably believes that there is criminal activity, a failure to comply with a legal obligation,
a miscarriage of justice, or a risk of health or safety to an individual. Injustice may be
considered a suitable cause for breach. However, great care must be taken when using the
media to highlight concerns over patient welfare when breaches may cause distress to patients
or their relatives and result in disciplinary proceedings.

Public Health

Public health is the overarching aim of healthcare and there are circumstances where
disclosure outweighs the benefits of individual privacy. Historically, doctors have been
required to provide epidemiological information by compulsory reporting of specific
communicable diseases or industrially related disease, governed by the Public Health (Control
of Disease) Act 1982. Up to 40% of patients with HIV are not aware of their diagnosis on
admission to intensive care. Dealing with a newly diagnosed patient, when they do not have
the necessary capacity to permit disclosure of the information to at-risk partners or contact
tracing is legally and ethically challenging. The local HIV team should preferably be involved
in such circumstances. Disclosure of a patient's HIV status to a third party may be justified in
exceptional circumstances with compelling reasons, for example, partner pregnancy or
unprotected sexual contact. If at all possible, the patient must be given the opportunity to
consent to the disclosure first.
Ideally, the ethical duty of confidence persists after a patient's death. For public health
reasons, personal data are available to the public audience in the form of death certification.
Inclusion of HIV/AIDS on certification may therefore be provocative. Doctors are required to
be honest and full in their disclosure. If a serious communicable disease has contributed to a
patient's death, this must be recorded on the death certificate. 11Information relating to serious
communicable disease should be passed on to the relevant authorities, while preferably
maintaining anonymity to improve control and maintain surveillance. This includes HIV,
tuberculosis, and hepatitis B and C.

Disclosures to relatives, friends, or third parties

In a critical care setting, it may seem unreasonable to refuse to provide information to a next-
of-kin when a patient is seriously ill as this may be in the patient's overall best interests. There
is no legal definition of next-of-kin, although, under Section 26 of the Mental Health Act
1983, the patient's husband or wife, including civil partner, takes precedence for taking
responsibility for the patient in the context of mental illness. In this context, if separated, the
partner remains the legal next-of-kin until they are divorced unless an alternative person is
nominated. Channelling information through one next-of-kin places some limits on the extent
of disclosure. Information is accessible to third parties when requested by employers,
insurance companies, and lawyers. Doctors are required to maintain an honest statement, not
give opinion, and use substantiated evidence.

In conclusion, Health care professionals must be vigilant to the duty of confidentiality and the
legitimate exemptions. This applies when caring for patients, communicating with colleagues,
and maintaining records. When a disclosure is contemplated, each case must be considered on
its own merits. In such cases, it is advisable to consult with senior colleagues, your hospital
legal representative or local Caldicott guardian, or medical defence union.
 (b)

A patient's bill of rights is a list of guarantees for those receiving medical care. It
may take the form of a law or a non-binding declaration. Typically a patient's bill of
rights guarantees patients information, fair treatment, and autonomy over medical
decisions, among other rights.

1. The Right to Medical Care

Every person in need of medical care is entitled to impartial access to treatment in accordance
with regulations, conditions and arrangements obtaining at any given time in the government
health care system.
In a medical emergency, a person is entitled to receive emergency medical care unconditionally in
any health facility without having to pay any deposits or fees prior to medical care.
Should a medical facility be unable to provide treatment to the patient, it shall, to the best of their
facility, refer him/her to a place where he/she can receive appropriate medical care.
2. Prohibition of Discrimination.
No health facility or health provider shall discriminate between patients on ground of disease,
religion, political affiliation, disability, race, sex, age, social status, ethnicity, nationality, country
of birth or other such grounds.
3. Participation on decision – making
Every citizen has the right to participate or be represented in the development of health policies
and systems through recognized institutions.
4. A healthy and safe environment
Everyone has the right to a healthy and safe environment that will ensure physical, mental and
social well-being, including adequate water supply, sanitation and waste disposal as well as
protection from all forms of environmental dangers such as pollution, ecological degradation and
infection.
5. Proper Medical Care
A patient is entitled to appropriate health care with regard to both its professionalism and quality
assurance based on clinical need.
6. Be treated by a named health care provider
Everyone has the right to know the identifiable and professional position of the person providing
health care and therefore shall be attended to by clearly identifiable health care provider.
7. Training and Research
The participation of a patient or client in clinical training programs or for the purpose of obtaining
information shall be voluntary and informed with written or verbal consent – and consent shall be
witnessed.
8. Right to safety and security
The patient has the right to safety and security to the extent that the practices and installations of
the health facility do no harm.

9. Receiving visitors
A patient hospitalized in a health facility is entitled to receive visitors at the times, and according
to the guidelines provided by the facility management.
10. Informed consent
Every patient has the right to be given adequate and accurate information about the nature of one’s
illness, diagnostic procedures, the proposed treatment for one to make a decision that affects any
one of these elements.
The information shall be communicated to the patient at the earliest possible stage in a manner
that he/she is expected to understand in order to make a free informed, and independent choice.
However, the clinician may withhold the medical information from the patient concerning his/her
condition if he/she strongly feels that by giving this information, it is likely to cause severe harm
to the patient’s mental or physical health.
The way in which informed consent may be given.
a. Informed consent may be given verbally or in writing or demonstrated by patient’s behavior.
Consent should be witnessed.
b. In a medical emergency, informed consent shall be given as soon as possible afterwards.
The patient should be kept informed if the institution is proposing to carry out or undertake human
experimentation or some other educational or research project. The patient has the right to decline
to participate in such activities.
11. Medical Care without consent
A health provider may give medical treatment without informed consent of the patient if:
a. The patient’s physical or mental state does not permit obtaining his her informed consent
b. It is impossible to obtain the consent of the patient’s representative or of the patient’s guardian,
where the patient is a minor or an incapacitated person.

12. Refusal of treatment

a. A person may refuse treatment and such refusal shall be verbal or in writing provided that such
refusal does not endanger the health of others.
b. But the health provider may perform the treatment against the patient’s will if the facility
management has confirmed the following conditions that:
i. The patient has received information as required to make an informed choice.
ii.The treatment is anticipated to significantly improve the patient’s medical condition.
iii.There are reasonable grounds to suppose that after receiving treatment, the patient will give
his/her retrospective con sent.
c. When the refusal of treatment by the patient or his/her authorized representative interferes with
the provision of adequate treatment according to professional standards, the relationship between
the patient and the health provider shall be terminated with reasonable prior advance notice.
13. Be referred for a second opinion
Every person has the right to be referred for a second opinion with or without request or when
indicated.
14. Continuity of Care
No client shall be abandoned by a health care professional worker or a health facility which
initially took responsibility for one’s health.

15. Confidentiality and privacy

Patients have the right to privacy in the course of consultation and treatment. Information
concerning one’s health, including information regarding treatment may only be disclosed with
informed consent, except when required by law or on court order.
Facility management shall make arrangements to ensure that health workers under their direction
shall not disclose any matters brought to their knowledge in the course of their duties or their
work.
Health facility or health worker may however pass on medical information to a third person in any
of the following cases:
i. That the disclosure is for the purpose of the patient’s treatment by another health worker.

ii. That disclosure of the information is vital for the protection of the health of others or the public,
and that the need for disclosure overrides the interest in the information’s non-disclosure.
iii. That the disclosure is for the purpose of publication in a medical journal or for research or
teaching purposes if all details identifying the patient have been suppressed.
16 The Patient’s Right to Medical Information
The patient shall be entitled to obtain from the clinician or the medical facility medical
information concerning himself/herself, including a copy of his/her medical records.
17. Custody of Medical Records:
The Ministry of Health shall be the legal owner and custodian of the medical records and will
ensure that the confidentiality be the responsibility of all health workers.
18. Medical records Retention (Medical archives)
1. General - 25years or 3 years after death
2. Obstetric: - 25 years after the birth of the child (including still birth)
3. Psychiatric: - Life time of the patient or 3years after death
At the conclusion of periods set out above, the records may be destroyed but there is no obligation
to do so. For research, clinicians may ask for indefinite retention.
19. Right to Redress
Every health facility shall designate a person or a committee to be responsible for the observance
of patient rights, whose duties shall be:
a. To give advice and assistance to a patient as to the realization of her/his rights spelt out in this
document.
b. To receive, investigate, and process patient’s complaints. Complaints regarding the quality of
medical care shall be referred to the attention of the facility in-charge.
c. To educate, and instruct all medical and administrative staff in the facility in all matters
regarding the patient’s rights.

In conclusion, the above are the fundamental patient’s rights and ways of promoting them.