CASE 3 A Case of Texting N Back

1. Rogelio, Ma. Graciela Salcedo, Von Edward Roque, Marianne Saldana, Emanuel Ruanto, Ma. Theresa Sales, Ma. Stephanie Sabalvaro, DyanKristelSalonga, Cryscel Anne Salac, Carmina Nina San Diego, Phoebe Salazar, Janelle San Pedro, Regina Salazar, RiccelSanez, John Ericson CASE 3A Case of Texting N Back

2. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

3. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

4. CASE 3 • PK, a celebrity singer was driving at fast speed at EDSA when he hit a 10 wheeler truck with no tail lights. His car turned turtle several times. He was brought to the hospital emergency room where an x-ray examination revealed multiple rib fractures and a major fracture in the thigh. • He was referred to Radiology for a multiple slice chest CT to rule out fat embolism. You were the radiology resident assigned in the Section who assisted the procedure.

5. CASE 3 • Your friends in the hospital texted and called you to ask: “What happened to dear PK, he is our idol?” Why was a CT done? What was the result of the procedures?” • Since the people who texted you were your friends, co-residents and co-healthcare workers in the hospital, you texted back what happened to PK.

6. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

7. “What happened to dear PK, he is our idol? Why was a CT done? What was the result of the procedures?” • “Since the people who texted you were your friends, co-residents and co-healthcare workers in the hospital, you texted back what happened to PK.”

8. Medical professionals did not preserve the principle of confidentiality. This was exemplified when: • Other medical professionals (co-residents and co-healthcare) who are not part of the attending medical teaminquired regarding the status and well-being of a private patient. • The attending radiologist disclosed private information by texting back.

9. Physicians have a prima facie obligationto preserve confidentiality, but such prima facie duties can be overridden for weighty reasons and not just by mere curiosity. • When confidentiality is breached, no matter what the weight of the argument, physicians are blameworthy… Reference: Textbook of Healthcare Ethics 2nded.

10. Breaching a confidence and violating a trust are not now, nor can they ever be, “good” things. • But they can, on the grounds of harm and benefit to others, be a better, and often far better, alternative than passively allowing great harm to occur. Reference: Textbook of Healthcare Ethics 2nded.

11. Medical professionholds confidentiality of the patient-physician relationship isrecognized in the current Code of Medical Ethics of the American MedicalAssociation: • In most states, either by statute or case law, disclosure ofmedical information is prohibited without consent of the patient. • Onestate court, after observing that the privacy right of patients warrants constitutional protection, ruled that patients mustbe able to secure medical services without fear of betrayaland unwarranted embarrassing and detrimental disclosure of private information. • The same court added that the obligation ofmedical confidentiality relative to patient records and informationapplies not only to physicians but to hospitals as well. Reference: Smith and Berlin, Malpractice Issues in Radiology; AJR 2001; 176:599-602

12. Radiologists should take reasonable care to keep statusconfidential, with access provided only to those health careprofessionals involved in the patient's care. • Reasonable carerequires, at a minimum, adherence to all applicable laws andinstitutional guidelines, as well as observance of commonsenseprecautions such as limiting medical record access in potentially sensitivecases. Reference: Smith and Berlin, Malpractice Issues in Radiology; AJR 2001; 176:599-602

13. The nature of confidentiality obligation is to ensure that the information is seen only by those who need to see it in the patient’s interest. • If others wish to have access to this information for other purposes, for instance for research, they may access and use it with patient’s consent, or at least receive it only in an anonymous form. Reference: R E Ashcroft, MA, PhD & P R Goddard, MD, FRCR; Ethical Issues in Teleradiology; The British Journal of Radiology, 73 (2000), 578-582.

14. As physicians, radiologists have both a legal and an ethical responsibilityto respect patient confidentiality. • The radiologist’s relationship with a patient ranges from interpreting a radiograph, in which case there is usually no direct contact, to performing a diagnostic or interventional study, where one does have some degree of direct contact with the patient. The patient’s right to confidentiality is the same, no matter what the depth of the doctor-patient relationship. • Unauthorized disclosure to third partiesand discussion of a patient’s disease in public areas of the hospital are breaches of confidentialityagainst which all physicians must constantly be on guard. Reference: Douglas L. Brown, MD.Patient Confidentiality in Radiology. Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School 75 Francis Street, Boston, MA 02115.

15. Section 6. The physician should hold as sacred and highly confidential whatever may be discovered or learned pertinent to the patienteven after death, except when required in the promotion of justice, safety and public health. Reference: CODE OF ETHICS OF THE PHILIPPINE MEDICAL ASSOCIATION

16. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

17. CONFIDENTIALITY • Shows a respect for an individual's autonomy and their right to control the information relating to their own health. • In keeping information about the patient’s secret the doctor is acting beneficently. • Disclosing information without the patient's consent can damage the patient. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

18. CONFIDENTIALITY • Confidentiality is not an ethical principle in itself. It can be characterized as a duty by some health professionals. • It involves a respect for autonomy and also beneficence towards the patient and a desire to act non-maleficently. • Breaking confidentiality to protect the safety of a third party is seen as reasonable. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

19. DISCLOSURE OF INFORMATION • Where serious harm may occur to a third party, whether or not a criminal offence, e.g. threat of serious harm to a named person. • Where a doctor believes a patient to be the victim of abuse and the patient is unable to give or withhold consent to disclose. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

20. DISCLOSURE OF INFORMATION • Where, without disclosure a doctor would not be acting in the overall best interests of a child or young person who is his/her patient and incapable of consenting to disclosure. • When, without disclosure the task of preventing or detecting a serious crime by the police would be prejudiced or delayed. • When, without disclosure the task of prosecuting a serious crime would be prejudiced or delayed (e.g. a patient tells you that he killed someone several years ago). Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

21. DISCLOSURE OF INFORMATION • Where a doctor has a patient who is a health professional and has concerns over that person’s fitness to practice and posing a serious danger to patients in his or her care. • Where a doctor has concerns over a patient’s fitness to drive. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

22. CONFIDENTIALITY • For instance if a doctor were to reveal privileged information about a celebrity patient to the newspapers then this would be the very reverse of beneficent i.e. maleficent. • Maintaining confidentialitycan therefore also be seen as non-maleficent. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

23. BENEFICENCE • “First principle" of morality, the dictum "do good and avoid evil“ • Is a "middle principle" insofar as it is partially dependent for its content on how one defines the concepts of the good and goodness. • As a middle principle, beneficence is not a specific moral rule and cannot by itself tell us what concrete actions constitute doing good and avoiding evil. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

24. BENEFICENCE • Principle of beneficence in the Catholic tradition are: 1) Never deliberately kill innocent human life (which, in the medical context, must be distinguished from foregoing disproportionate means). 2) Never deliberately (directly intend) harm. 3) Seek the patient’s good. 4) Act out of charity and justice. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

25. BENEFICENCE 5) Respect the patient’s religious beliefs and value system in accord with the principle of religious freedom. 6) Always seek the higher good, that is, never neglect one good except to pursue a proportionately greater or more important good. 7) Never knowingly commit or approve an objectively evil action. 8) Do not treat others paternalistically but help them to pursue their goals. 9) Use wisdom and prudence in all things, that is, appreciate the complexity of life and make sound judgments for the good of oneself, others, and the common good. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

26. NON-MALEFICENCE • Primum non nocere, commonly translated as "first, do no harm," is often considered to be a corollary to the principle of beneficence. • In this respect, it shares the same characteristics of beneficence considered as a middle principle. • It is sometimes interpreted to imply that if one cannot do good without also causing harm, then one should not act at all. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

27. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

28. INFORMED CONSENT • It is the right and responsibility of every competent individual to advance his or her own welfare. • This right and responsibility is exercised by freely and voluntarily consenting or refusing consent to recommended medical procedures, based on a sufficient knowledge of the benefits, burdens, and risks involved. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

29. INFORMED CONSENT • The ability to give informed consent depends on: 1) Adequate disclosure of information 2) Patient freedom of choice 3) Patient comprehension of information 4) Patient capacity for decision-making Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

30. INFORMED CONSENT • By meeting these four requirements, three necessary conditions are satisfied: 1) That the individual’s decision is voluntary 2) That this decision is made with an appropriate understanding of the circumstances 3) That the patient’s choice is deliberate insofar as the patient has carefully considered all of the expected benefits, burdens, risks and reasonable alternatives. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

31. INFORMED CONSENT • Legally, adequate disclosure includes information concerning the following: 1) Diagnosis 2) Nature and purpose of treatment 3) Risks of treatment 4) Treatment alternatives Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

32. INFORMED CONSENT • Depending on the circumstances, consent may take on two other forms. • In cases where individuals are brought to the hospital in an unconscious state or with no decision-making capacity,consent can bepresumed, provided that the procedures performed are necessary and cannot be postponed until the person has regained consciousness or decision-making capacity. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

33. INFORMED CONSENT • It also may happen that a surgeon sees the critical need of more extensive surgery in the course of an operation. In these circumstances, there may be no time to contact the spouse, parents or surrogate of the unconscious patient. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

34. INFORMED CONSENT VICARIOUS CONSENT • For incompetent or incapacitated individuals, this right and duty of the patient to give consent is to be exercised on his or her behalf by a surrogate. • It is regulated by individual state and federal laws, following various standards of surrogate decision-making, including substituted judgment and best interests. Reference: Healthcare Ethics. http://www.ascensionhealth.org/ethics/public/key_principles/informed_consent.asp

35. Objectives: • To present the case • To enumerate the ethical issues / problems of the case • To enumerate the ethical principles violated • To enumerate the ethical principles upheld • To give recommendations regarding the case

36. Breach of the principles of medical ethics would eventually result to bad doctor-patient relationship and possible legal sanctions.

37. BIOETHICS COMMITTEE: ♣ Reprimand and give penalty to the resident for disclosing confidential information. ♣ Assess the damage: gather all the co-residents and healthcare workers who were texted, and determine the extent of news leakage.

38. BIOETHICS COMMITTEE: ♣ Make sure that the leaked information is truthful and accurate, with correct interpretation of the imaging results. ♣ The resident should tell the patient the truth regarding the leaked information, and apologizefor the breached confidentiality.

39. BIOETHICS COMMITTEE: ♣ If the extent of leakage has reached the general public, try to work with the patient to arrange a press conference on how he wants the issue to be dealt with. Remember to always protect the right and dignityof the patient.

40. BIOETHICS COMMITTEE: ♣ If the patient wants to sue or take legal actions, try to work out first the best possible arrangements that would still maintain the reputationof the hospital. Due compensation could be given.

41. Thank You