Medical College of Georgia

 School of Medicine | A-Z Index | MCG Home  

The Language of Bioethics (Glossary)

Objectives

Goals

Required Reading

Clinical Vignettes

Informed Consent

Confidentiality

Clinical Vignettes

Topical Questions

Suggested Reading/Resources

References & Resources

Informed Consent and Confidentiality

Objectives

To explore the physician's ethical and legal responsibilities for informed, voluntary consent and confidentiality of patient information; and circumstances in which disclosure can be made to others who are likely to be affected (i.e., breaching confidentiality).

Goals

1. To understand the purpose of the consent process.
2. To understand competency and non-competent patients, the concepts of best interest, substituted judgment and surrogate consent.
3. To understand the right of the patient to self determination including refusal of treatment.
4. To understand the limits of confidentiality and when it can be breached.

Required Reading

1. Introduction to Clinical Ethics  by Fletcher, Miller, Lombardo and Marshall. Second Edition.
   "Respecting Privacy and Confidentiality," p 41-53
   "Communications, Truth-telling, and Disclosure," p55-70
   "Determining Patient Capacity to Share Decision Making," p 71-88
   "The Process of Informed Consent," p 89-105
2. Code of Medical Ethics, American Medical Association
   "Principles of Medical Ethics," p. xiv
   "Fundamental Elements of the Patient-Physician Relationship," p. xxxix-xl
   "Informed Consent," 8.08
   "Confidentiality," 5.05 ff
   Note: Many of these AMA statements are in Doctor's Dilemma

Clinical Vignettes
Excerpted from Clinical Ethics  (4^th Edition) by Jonsen, Siegler, and Winslade.

1. Competent Refusal, 2.4.1; p 58-59.
2. Refusal on Grounds of Unusual Belief, 2.4.2; 59-60.
3. Enigmatic Refusal, 2.5.3; p 77-80.

Informed Consent

1. Functional definition of informed consent

A. Disclosure of all pertinent information

1. Physician's responsibility for expertise
2. Determination of what is clinically significant

B. Content of Disclosure

1. Current medical status and likely course if no treatment
2. Interventions that might improve prognosis-risks, benefits, probabilities and uncertainties of these interventions
3. Opinion of alternative interventions
4. Recommendation based on physician's best clinical judgment
5. Interventions will vary depending on whether the clinical condition is emergent, semi-emergent or elective.
6. Research

C. Information must be understood by the patient

1. Comprehensive explanation in patient's vernacular if necessary
2. Patient competence
3. The role of surrogate decision-makers

D. Voluntary, freely given

1. Coercive effect of trust in and dependency upon the physician
2. Family and social pressures

E. Patient competence--the ability to make autonomous, intelligent decisions

1. Ability to understand
2. Ability to evaluate
3. Ability to communicate

F. General purpose of the consent process: To provide as much information as possible and assure intelligent and voluntary decisions to accept or reject proffered care.

2. Ethical Bases

Respect for the human dignity of each patient and the patient's bodily, psychological and emotional integrity.

A. Respect for the full dignity of human life
B. A balance of autonomy and beneficence, and non-maleficence
C. Physician's fiduciary responsibility
D. Professional guidelines

3. Legal Expression

A. Battery--Requirement for legal authorization
B. Informed Consent Doctrine--Legal duties and remedies
C. Georgia's Medical Consent Law

1. Who may consent?
2. What must be disclosed?
3. Exceptions to the rule

Confidentiality

1. Basic elements

A. Respect for patient's privacy and autonomy
B. Prevention of harm to patients
C. Fiduciary relationship between patient and physician
D. Service to the common good

2. Obligations to respect confidentiality

A. Professional ethical guidelines
B. Legal standards
C. Important exceptions

Clinical Vignettes

Competent Refusal

Ms. T.O. is a 49-year-old surgical nurse. Five years ago, she had a resection of a stage I infiltrating ductal carcinoma. She visits her physician after discovering a mass in the contralateral breast and noting axillary swelling. Studies reveal stage II breast cancer with involved nodes. Following surgery, 10/16 nodes were positive. Chemotherapy and radiation are recommeded and Ms. T.O. is told that the statistics for her condition suggest that, with treatment she can expect a disease-free survival rate at 10 years of 50 percent; without treatment, she has a 10 percent chance. She accepts chemotherapy, but after the first course, during which she has experienced significant toxicity, she informs her physician that she no longer wants any treatment. After extensive discussions with her physician and with her two daughters, she reaffirms her refusal of chemotherapy.

Refusal on Grounds of Unusual Belief

Mr. G. comes to a physician for treatment of peptic ulcer. He says he is a Jehovah's Witness. He is firm believer and knows his disease is one that may eventually require administration of blood. He quotes the biblical passage on which he bases his belief: "That you abstain from meats offered to idols and from blood..."(Acts 15:28). The physician inquires of her Episcopal clergyman about the interpretation of this passage. He reports, after some research, that no Christian denomination except the Jehovah's Witnesses takes it to prohibit transfusion. The physician considers her patient's preferences impose an inferior standard of care. She wonders whether she should accept this patient under her care.

Enigmatic Refusal

Mr. Cure presented with signs and symptoms suggestive of bacterial meningitis. When he was told his diagnosis and told he would be admitted to the hospital for treatment with antibiotics, he refused further care, without giving a reason. The physician explained the extreme dangers of going untreated and the minimal risk of treatment. The young man persisted in his refusal. Other than this strange adamancy, he exhibited no evidence of mental derangement or altered mental status that would suggest decisional incapacity.

Topical Questions

1. What should patients be told about treatment procedures proposed to them? How much detail and how should it be communicated?
2. What if a patient is not very sophisticated? What if he is likely to be frightened or refuse treatment that is in his best interest?
3. Should an adult ever be treated without or against his consent? If not, why? If so, when?
4. Is fully informed, voluntary consent ever possible? How can it best be approximated?
5. What are physicians' professional responsibilities to patients for confidentiality?
6. Should a patient's enigmatic refusal be accepted? Should there be some inquiry to determine some [hidden] rationale?

Suggested Readings/References

1. The Doctor's Dilemma by Martin, Reese, Browne and Baros-Johnson
   "Bowsher Case"
   "Harper Case"
   "King Case"
2. The Hippocratic Oath (Located within Doctor's Dilemma)
3. Ethics Manual, Fourth Edition, American College of Physicians
   "Physician and Patient"
   "The Physician and Society"
   "Conflicts of Interest"
   "Consent"
   "Confidentiality"
   "Decisions about Reproduction"
4. Official Code of Georgia, 31-9-1 through 31-9-6.1 and
   24-9-40.
5. Martin, RM. Some ethical issues in the disclosure of progressive diseases of the nervous system. Southern Medical Journal. July 1978; Vol 71(7): 792-794.
6. MCG Hospital and Clinics Policies and Procedures, "Request and Informed Consent to Surgical and/or Diagnostic Procedure."

Medical College of Georgia

Please email comments, suggestions or questions to
Alan Roberts, aroberts@mail.mcg.edu.
August 05, 2002