Truth-Telling and Confidentiality

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Truth-Telling and Confidentiality

• Bioethics, Chapter 4 (105-110) and Garrett
  Supplement (111-130)

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Truthfulness

• Truthfulness can be specified by two hypothetical
  commands
• If you communicate, do not lie (refusing to
  communicate is not lying)
• You morally must communicate, if others have a
  right to communication (not everyone has a right
  to know what you know, or all you know)
• (Vaughn doesnt try to define truthfulness these
  specifications are from Garrett, p112)

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Truthfulness

• What is lying?
• Garrett cites a traditional understanding of
  lying, calling it speech against the mind
  something at odds with what the speaker believes
  to be true p112
• That definition is rejected, though, as it leads
  us to classify assertions in play acting, humor,
  games, etc., as lies, which seems wrong.
• Instead, well call those speech acts against the
  mind, falsehoods.

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Lying (cont.)

• Lies will then be
• falsehoods uttered in circumstances where others
  have a reasonable expectation of the truth
• Why not where others have a right to the truth?
• A lie surely does occur when we utter falsehoods
  to those with a right to the truth, right?
• Consider Is your car in the parking lot?

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Reasonable Expectation

• Garrett provides 3 ways to assess reasonable
  expectation
• The place of communication (in public, in a
  church, synagogue, or mosque, at a funeral, etc.)
• The roles of the communicators (teacher/student,
  boss/employee, etc.)
• The nature of the truth involved (personal
  matters sex, finances, secret ambitions, etc.)
• All 3 are connected with the obligation of
  confidentiality and the right of privacy

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Reasonable Expectation

• Special contexts that affect reasonable
  expectation
• business
• advertising
• law (self-incrimination)
• volunteering information
• being asked

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Right to the Truth

• In medical contexts we have a right to the truth
  from others, or conversely, an obligation to
  provide it to them, regarding the
• information in informed consent
• information paid for by patients
• information needed for important nonmedical
  decisions

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Right to the Truth

• Like what important nonmedical decisions?
• Like the right of patients to know that they are
  dying, which is important for settling
• financial affairs
• personal affairs
• making peace with God
• settling disputes with family, friends, enemies
• simply saying goodbye

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Right to the Truth

• The Placebo Problem
• Placebos involve medical deception. Can they ever
  be used outside of research?
• (if you consent to participate in a research
  study knowing you may not be treated with active
  pharmacological agents, the deception is trivial)

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Right to the Truth

• Garrett discusses all the ways placebos can be
  used to good effect. Then says this
• If the physician says I am going to prescribe
  something that often helps in these cases and has
  no bad side effects,
• it is hard to see how he is deceiving the
  patient.
• Certainly he is not lying.
• In such a presentation, the patient knows what
  she or he needs to know in order to give informed
  consent.
• No untruth is spoken, and
• no information to which the patient has a right
  is suppressed
• Does this sound right to you?! (note my italics)
• What holiday would this need to fall on?

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Confidentiality

• Vaughn discusses consequentialist and
  non-consequentialist justifications for valuing
  confidentiality.
• Consequentialist reasons confidentiality is
  necessary to protect
• Physician/patient trust
• Patients access to insurance
• Patients relationships (familial and other)
• Patients public stature

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Confidentiality

• Non-consequentialist reasons
• You have a simple right to privacy based on the
  good of self-determination and
  self-determination is limited when you cannot
  control the distribution of personal information.
  
• Also, if a physician has promised (perhaps
  implicitly) not to divulge information about you,
  the promise is ethically binding.

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Confidentiality

• Confidentiality is concerned with keeping
  secrets. Garrett -p117
• A secret is knowledge that a person has a right
  or obligation to conceal. Garrett again, p117
• -note that that isnt true. A secret is simply
  knowledge intentionally concealed
• There are
• Natural secrets
• Promised secrets
• Professional secrets

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Confidentiality

• Natural secrets
• Secrets whose revelation would cause harm by
  nature
• Letting others know what you know about someones
• binger
• social disease
• Infidelity
• foot odor problem
• bad grade

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Confidentiality

• Promised secrets
• knowledge we have promised to conceal. -p118
• The special evil of revealing promised secrets
  arises from the harmful effects of breaking
  promises. p118
• -note that that is false for Kantians,
  deontologists generally (again with consequences
  sheesh!)

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Confidentiality

• Professional secrets
• knowledge that, if revealed, will harm not only
  the professionals client, but will do serious
  harm to the profession and to the society that
  depends on the profession for important
  services.

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Confidentiality

• Professional secrets (cont.)
• Exceptions
• Medical consultation (to figure out how to treat)
• State law (gun and knife wounds need reporting)
• Court decisions (similar logic to law, different
  standard)
• Unusual relationships (if doctors role is to
  determine health status for company, army, etc.)
• Proportionality (good of revelation outweighs bad
  of divulging a confidence)

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Confidentiality

• Professional secrets (cont.)
• Exceptions (cont.)
• Family (law has changed to exclude immediate
  family from doctor-patient confidence family is
  not considered the patient as it once was)
• Children and adolescents (teen pregnancy, social
  disease, drug use, etc. states forbid to varying
  extents physicians sharing such information with
  parents)
• Media publicity for celebrities and politicians
• Third party payers (insurance companies need to
  know medical information)
• Public good (AIDS and HIV information)
• HIV-positive provider (must disclose information
  to patient?)

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Confidentiality

• Read about the Tarasoff case and A Duty to Warn
  in Vaughn, p. 109.
• Read Applying Major Theories on p. 110.

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References

• Vaughn, L. (2010). Bioethics
• Garrett, T. M., Baillie, H. W., Garrett, R. M.
  (2001). Health Care Ethics (4th Edition)