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Commentary.

The ease with which families and health care professionals abandon their usual commitment to individual autonomy, honesty, and respect for persons where a patient is older and perceived to be at peril is illustrated in this case by the conduct of Mr. G's cardiologist, his brother-in-law, and his adult children. When what we ethically expect of each of these actors regarding Mr. G's privacy is compared against their actual behavior, the conclusion necessarily is one of paternalism at its worst.

The cardiologist, as treating physician, clearly has both a fiduciary and contractual obligation to hold confidential from third parties any information that comes into her possession through her professional relationship with her patient. Mr. G had not given his express permission for release of information to his brother-in-law, and the cardiologist had neither a factual basis nor a valid ethical justification for inferring such authorization. Even if the cardiologist knew (she did not) about Dr. H's close relationship with the patient, leaping to the assumption that therefore Mr. G would have no objection to opening his medical record to his brother-in-law would be inappropriate. It would have been easy enough, and more respectful, to check directly with Mr. G concerning his preference regarding privacy. If the cardiologist's decision to reveal information to Dr. H was based on their common membership in the medical "fraternity" rather than the patient's clear permission, the disrespect for Mr. G's privacy was even more egregious.

The adult children are somewhat less blameworthy, since they only received information from their uncle concerning Mr. G, rather than revealing information about him to another. Nonetheless, their participation in this conspiracy to bypass their father in the name of protecting him constitutes disrespect for his dignity as a person. At the least, once they had been told the unfortunate news by their uncle, the children should have taken a cue to probe their father directly to plumb what information, if any, he wished to share with them himself. It would have been preferable for them to converse with Mr. G, rather than to treat him as though he were a helpless, inanimate object of a conversation to be carried on with someone else.

Dr. H occupies several interrelated roles in this case: relative, friend, and physician. However benevolently motivated, relatives and friends have no right to intrude on the privacy of individuals, at least as long as the patient is still decisionally capable. Dr. H showed lack of confidence bordering on distrust and disrespect by going behind Mr. G's back to discuss his case with the cardiologist. Mr. G had not retained him as a formal medical consultant. Thus, Dr. H had no special warrant either to obtain or to reveal confidential information about him. Indeed, Dr. H may have proceeded without asking for Mr. G's permission precisely because he wasn't sure that it would be forthcoming.

Beyond abrogation of the principles of respect for the dignity of persons, honesty, and autonomy, practical harm might result from the brother-in-law's conduct. Specifically, if Mr. G learns of Dr. H's transgression against his privacy, a loss of trust and friendship may occur. Even if Mr. G does not become aware of this brother-in-law's secret activities, his children know about them. They are likely to realize that, if Dr. H is capable of disrespect toward Mr. G in this way, he would have little compunction about paternalistically violating their own privacy in the future. Their faith in his commitment to fidelity would be weakened, and they would lose a valuable confidant and advisor. On a broader scale, the children's trust in physicians generally might be shaken, threatening their own future medical care by making them reluctant to disclose sensitive information to their own physicians.

[Marshall B. Kapp is professor of community health and director, Office of Geriatric Medicine & Gerontology, Wright State University School of Medicine, Dayton, Ohio.]
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Title Annotation:Case Study: The Voluble Brother-in-Law; confidential communications between doctor and patient
Author:Kapp, Marshall B.
Publication:The Hastings Center Report
Date:Jan 1, 1993
Words:645
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