RUNNING HEAD: RECONSIDERING THE BOUNDARIES OF PATIENT 1

CONFIDENTIALITY

Reconsidering the Boundaries of Patient Confidentiality When Another

Individual’s Health Is Involved

Alexis D. Lee

James Madison University

Reconsidering the Boundaries of Patient Confidentiality When Another

Individual’s Health Is Involved

Patient confidentiality between nurses and physicians is a sacred value in healthcare that is

always going to remain important. However, the idea of confidentiality gets complicated when

other parties are involved such as the law or another person. Eth (1988) suggests that a reason

confidentiality may be broken is that providers vow to protect all human life, and when another

individual’s health is in jeopardy then they may decide to violate the rules. When nurses are

assessing patients, information is disclosed because they know they can trust that it will stay private

and may not consider that it may place the nurse in an uncomfortable place. Breaches of patient

confidentiality ranked top 5 in a study focused on most frequent ethical and patient care issues

among nurses (Ulrich, et al.). It is important to make the right decision for all individuals when

providing care, so we must be educated and considerate about the best way to make these decisions.

Background

A particular time when I encountered an ethically difficult situation was in my Women’s

Health Clinical in semester two. During my week in the nursery, I was able to observe a woman’s

cesarean section that produced a healthy baby boy. This was not the first cesarean section for the

patient, she had one with her two-year-old daughter. The reason she had her first c-section was

because after 4 hours of labor there was no dilation or effacement so they needed to operate. With

this second pregnancy, they planned to perform the c-section early and ahead of time. While

charting after the delivery with my nurse preceptor, she explained that the mother had a history of

Herpes Simplex Virus and this was related to the reason she was unable to give birth vaginally.

Having a history of STD’s, HSV in particular can create a risk for vaginal delivery so a cesarean
RECONSIDERING THE BOUNDARIES OF PATIENT CONFIDENTIALITY 3

section is safer for the newborn’s health (Brown, Wald, Morrow, Selke, Zeh, Corey, 2003). Later

in the day when discussing the plan of care for the new mom, SBAR was given between two

nurses. During SBAR I heard the labor and delivery nurse say that the patient’s HSV history was

not to be mentioned when the newborn’s father/her partner returned because he was unaware of

the patient’s STD. The nurse listening did not react which was the professional thing to do. After

processing this information, I decided to discuss this with my clinical instructor later in the day. I

remained calm but was thinking how unsafe this was for the father and if it was legal. An

alternative to waiting and speaking with my instructor about the situation would have been to pull

my nurse preceptor aside and ask her directly about how situations like these are typically handled.

This situation caused me a moral distress and not a dilemma. In this situation it was clear

what the correct thing to do would be, however the rule of patient confidentiality made disclosing

the mother’s sexual health history unrealistic. Putting everything into perspective, this couple now

had two children together so there is a possibility they may conceive another which is putting the

father at risk all over again. Not telling the father he may have HSV is both risky and unjust. It

became difficult to be completely happy for the parents and their newborn knowing this

information. However, the patient of care was the mother so her health and safety took precedence.

If there were options to how the father could be informed it would be a dilemma.

Methods/Findings

To analyze this situation in clinical I am going to use JMU’s Eight Key Questions. The

Eight Key Questions are used to assist the JMU community in ethical decision making (Madison

Collaborative, 2013). The eight key questions are eight essential principles that were put together

to be considered and kept in mind when making an ethically sound choice. The eight principles
RECONSIDERING THE BOUNDARIES OF PATIENT CONFIDENTIALITY 4

were then turned into questions for a person to ask themselves as they make a decision. In

assessing my situation, the first value/question is “how can I act equitably and balance legitimate

interests?” I would try to discuss with my patient why it would be important to share having an

STD with her long time partner, at least trying to get her permission on the matter. The second

question is “what achieves the best short and long term outcomes for me and all others?” The

action to keep the mother’s history undisclosed so that it does not ruin her relationship or impact

her children’s relationship with their father. The third question is “what duties and/or obligations

apply” and it is our duty as nurses to always protect patient confidentiality unless child abuse or

elderly neglect is suspected. The fourth question is “what action best reflects who I am and the

person I want to become?” If I had full permission, I personally would tell the partner about the

HSV so he can get tested and protect himself as well. The fifth question is “how does respect for

freedom, personal autonomy, or consent apply?” With this question, it is completely up to the

patient who has the disease to decided when or how she will tell her partner, if she ever chooses

to do so. The sixth question discussing empathy is “what would I do if I cared deeply about those

involved?” I would urge the patient to tell her partner, find out why she has not already told him,

and try to find a solution together. The seventh question is “what do legitimate authorities expect

of me?” In the state of Virginia, it is not illegal to withhold whether or not you have an STD and

most hospital policies would not allow me to persuade the patient to discuss this information

with her partner. The eighth question is “what rights apply?” This question is answered simply

because all rights belong to the patient about informing her partner.

The American Nurses Association created a code for nurses to refer to and practice by to

be ethically correct. The provision that most applies to my situation is number three; “The nurse

promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (Code
RECONSIDERING THE BOUNDARIES OF PATIENT CONFIDENTIALITY 5

of Ethics for Nurses 2001). Using this part of the code can act as a gentle reminder that although

it would be ideal for the partner to become informed, ultimately it is my patient’s safety and

rights that takes priority. It is important to consider how her partner may react because he may

not respond in a calm or accepting manner. Although it would be ideal, his reaction could

involve hurting the mother and or children.

Conclusion

From this analysis, a lot can be learned about the ethical dilemmas and appropriate

decision-making. When faced with a problem that affects two people there is always the urge to

help/satisfy both individuals, especially when both are at risk. In my particular clinical

predicament, using the eight key questions is a structured way of assessing the pros and cons of

what decision to make. When this situation occurred in clinical, I should have asked more

questions of the nurse and tried to get more background information on the patient’s reasoning in

keeping her HSV private. Not asking questions can increase the distress in any situation, so

gathering all the data can contribute to proper decision making. Nurses naturally want to help

everyone they can, but processing all information and remembering our obligations to the patient

can reduce distress in ethical dilemmas.

References

American Nurses Association. Code of ethics for nurses with interpretive statements.

Washington, DC: American Nurses Association, 2015. Reprinted with permission.

Brown Z.A., Wald A., Morrow R.A., Selke S., Zeh J., Corey L. (2003). Effect of Serologic Status

and Cesarean Delivery on Transmission Rates of Herpes Simplex Virus From Mother to

Infant. JAMA. 289(2):203–209.

Eth, S. (1988). The Sexually Active, HIV Infected Patient: Confidentiality versus the Duty to

Protect. Psychiatric Ann; 18: 571-576.

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in

action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml

Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010).

Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced

Nursing,66(11), 2510-2519.