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The fundamental principle of confidentiality is that information held for a certain objective may not be given without consent to a third party. Ethics codes and law recognize the mental health client right to confidentiality; however, there are exceptions and controversies. The aim of this thesis is to review in brief these ethical and legal commitments and give a case example on one issue on confidentiality in a mental health setting.
Confidentiality is a commitment that restrains a body (psychologist, healthcare provider, or organization) from revealing information against the interest of the individual or body who gave it first. The fundamental principle of confidentiality is that information held for a certain objective may not be given without consent to a third party. Confidentiality is important to achieve the trust needed for the therapeutic bond between a client and a healthcare provider. Based on this definition, confidentiality is a commitment of a person towards another, while privacy is the information a person wants to keep and not to disclose to anyone else (New South Wales Consumer Advisory Group-Mental Health, 2004).
Ethical and legal confidentiality commitments in mental health
The Oath of Hippocrates states confidentiality, a principal confirmed by the UN Geneva Declaration in 1948. Ethically, confidentiality has two perspectives, the professional viewpoint, as it is an immediate precondition to ensure patient’s cooperation. Second is the duty viewpoint, since healthcare providers give a promise of confidentiality, either clearly or unspoken (implied), it is their duty to keep the promise. As the social scope is wider with competitive moral commitments; some suggest limits to confidentiality in one of two states of affairs, to achieve the patient’s best interest (rule of beneficence). Some suggest breaking confidentiality to achieve a public interest (rule of justice). In this state the question of decision making of what is in the best interest of the public is ambiguous (McClelland, and Thomas, 2002).
The report of the US Surgeon General (2000) summarized the confidentiality legal dilemma. It stated that law can either expand or submit confidentiality to the rule of beneficence or rule of justice. The US Supreme Court extended the principle of confidentiality based on providing psychotherapists with the best conditions to build trust and treat their patients is concisely in the public interest (psychotherapeutic privilege principle). On the other hand, states’ laws may differ as it is with the California Supreme Court ruling that psychotherapists had a commitment to protect third parties. There are areas of wider controversies especially with adolescents with alcohol or drug abuse combined with psychological problems. The report concluded that confidentiality is not absolute. This shows the importance of extending the discussions on the rules of beneficence and justice (US Department of Health and Human Services, Surgeon General Report, 2000).
The ambiguity of breaking confidentiality: An example case
The law recognizes the right of youth to make a decision about medical consultation (autonomy), and grants confidentiality in healthcare-related to them. Sanci and others (2005) presented a case for weighing confidentiality. A student welfare coordinator noticed the low academic performance of a 16 years old male student; during the discussion, he stated he hears a voice. On referral to the GP, the student requested that his mother not be informed, because of her illness and recent separation from the student father. That was the only condition the student made to see the GP, who succeeded to gain the student’s trust by explaining that exceptions to confidentiality will only be in case of risk of suicide, homicide, or abuse. On subsequent visits, the student described the impact of voices on his life; he had to quit school for days, he became socially isolated and stopped playing music which was his favourite hobby. The progressive course of his problems frightened him but still does not inform his mother. The GP judges a minimal risk of suicide; next, the GP expressed his appreciation for the student’s courage in discussing his problems and suggested referral to a psychologist. The GP advised the student to involve his mother as he may need her support, but the student agreed to see the psychologist on his own insisting that his mother should not know. The question is what the psychologist should do, he earned the student trust and managed successfully to manipulate the progress of his disorders, breaching confidentiality may reverse the whole procedure and make things worse for the psychologist to take over the case (Sanci and others, 2005).
Apart from legal consequences, the ethical controversy, in this case, is between the Deontological approaches that ethical principles governing an action are inherent rather than depending on its consequences. The second is the Utilitarianism approach where the concept involves all whatever good or bad consequences of an action. It looks that Deontological approaches are expressed in a healthcare organization’s written policies whereas discrepancies from written policies appear in the everyday practice of managing a case. When a client decides to seek advice, thus practising autonomy but giving up confidentiality as the client will show the personal self to the therapist. Further, for treatment to succeed, the client must change behaviour, thus giving up the right of autonomy. This is a part of the confidentiality issue to deal with in future research (Sweitzer, 2008).
Although the ethical and legal backgrounds of protecting confidentiality provide guidance to mental healthcare providers on when to breach confidentiality, yet terms are broad and general. Not all cases or situations are covered, and conflicts often emerge between commitment to confidentiality and breaking it. Further, look to the area of public interest and patient versus society benefits is needed for further clarification and precision.
- McClelland, R., and Thomas, V. (2002). Confidentiality and security of clinical information in mental health practice. Advances in Psychiatric Treatment, 8, 291-296.
- New South Wales Advisory Group-Mental Health Incorporated (2004). Issues Paper: Privacy and Confidentiality. Web.
- Sanci, L., A., Sawyer, S., M., S-L Kang, M., Haller, D., M., and Patton, G., C. (2005). Confidential health care for adolescents: reconciling clinical evidence with famil values. MJA, 183(8), 410-414.
- Sweitzer, E.M. (2008). Frontstage and Backstage Ethics in Mental Health: A Qualitative Case Study. Journal of Law, Ethics, and Intellectual Property, 2 (1), 1-11.
- U.S. Department of Health and Human Services. (2000). Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office.