Confidentiality & HIV

In this series of articles, our medical students will discuss a range of topics from medical ethics to the NHS to public health to medical conditions to clinical governance

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Is it ever acceptable to break patient confidentiality if you know that a patient's health status may be harming others?

This is a difficult question because we all know that the doctor patient relationship is of utmost importance as we need to maintain the patients trust in the medical profession. However, doctors also have a duty to protect the whole population.

Let’s apply some context to this question. Imagine that a man has walked into your clinic and he discloses that he has HIV, a serious sexually transmitted disease. He then explains that he will be entering a sexual relationship with a woman, who he has not told that he has HIV, and he will not be using any contraception. What would you do? You would surely be concerned for the health of the woman, however telling her the health status of the man would be breaching confidentiality.

Firstly, let’s look at some of the times, according to the GMC, when you can breach patient confidentiality:

1) The patient consents, whether implicitly (circumstances in which it would be reasonable to infer that the patient agrees to the use of the information, even though this has not been directly expressed) or explicitly (when the patient actually agrees) for the sake of their own care or for local clinical audit, or for other purposes.

2) The disclosure is of overall benefit to a patient who lacks the capacity to consent.

3) The disclosure is required by law, or the disclosure is permitted or has been approved under a statutory process that sets aside the common law duty of confidentiality.

4) The disclosure can be justified in the public interest.

If we consider the first point, the first thing to do would be to try to understand why they wouldn’t want to disclose the information on their own, which would prevent you from having to get involved. In my example scenario, one possibility could be that the man is scared that if he discloses the information, the woman may not be interested in him anymore. In this case, you would have to try to make the patient understand that not telling his female partner that he has HIV would put her in major danger. If the patient understands this and agrees to tell, then you have no further work to do. He may also ask you to tell the woman, which is also acceptable.

However, there could be another reason why the man refuses to tell the woman about his condition. Let’s look at the second point. The man could lack the capacity to understand the seriousness of his condition and believe it to be harmless. However, never assume that a patient lacks capacity. Firstly, a mental assessment must be made. If, after this assessment, you believe that the man lacks the capacity to understand how serious it would be if he knowingly transmitted HIV to another person, you can then tell the woman yourself. This would be not only be in the best interest of the man, but it would also be protecting her as well.

Another outcome of this situation is that the man has capacity and understands that he will be passing on HIV to the woman, however he still refuses to tell her. At this point, you’d have to think independently. According to the GMC, ‘there can be a public interest in disclosing information to protect individuals or society from risks of serious harm, such as from serious communicable diseases or serious crime’. Therefore, if you think that the woman is in severe danger, you can take the matter into your own hands.

However, there are factors to consider (taken from the GMC):

1) the potential harm or distress to the patient arising from the disclosure – for example, in terms of their future engagement with treatment and their overall health

2) the potential harm to trust in doctors generally – for example, if it is widely perceived that doctors will readily disclose information about patients without consent

3) the potential harm to others (whether to a specific person or people, or to the public more broadly) if the information is not disclosed

4) the potential benefits to an individual or to society arising from the release of the information

5) the nature of the information to be disclosed, and any views expressed by the patient

6) whether the harms can be avoided, or benefits gained without breaching the patient’s privacy or, if not, what is the minimum intrusion.

All medical ethics scenarios are complex – there are many angles to them. Therefore, you never have to reach a definitive conclusion.