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comes the task of the psychiatrist. We must protect the integrity of the psychiatric process and the patient's clear right to privacy. But we are also asked to recognize that some information, usually with the patient's consent, and for advantages important to the patient, may properly be released to third parties. Lastly, in certain rare and special cases, our obligation to society may supersede the patient's rights.
Finding this balance is often not easy. It could be destructive to a patient to refuse to give information about him to a third party having a legitimate right to it. It would be destructive to the patient to reveal too much information. It would be extremely destructive to the treatment process also if the psychiatrist were knowingly to collude in a manipulation of facts. This search for the proper balance is generally best carried out in cooperation and discussion with the patient in the course of which it is the psychiatrist's responsibility to determine whether the patient's consent is truly informed and not based on either misunderstanding or coercion.
Those rare and special circumstances in which a physician's obligation to consider hazards to society may outweigh obligation to preserve the privacy of the patient, are crises in which there is clear, present and extreme danger to life or limb directed by the patient toward others or self. Such crises are often technical treatment problems and should, if possible, be handled within the context of treatment. Possibly outside consultation may be of help and should be carefully considered. Once, however, if in the psychiatrist's judgment this extreme danger from the patient toward self or others can no longer be contained within the treatment, protection of the patient or others may require a breach of confidentiality. In these circumstances confidentiality should be broken only to the extent necessary.
The principle that confidentiality should only be broken to the minimum degree necessary to achieve its desired end applies to all circumstances in which third parties have a legitimate right to information. These will be dealt with in turn.
Among the most common third parties requesting information about the patient or his treatment are family members. Here the psychiatrist must judge whether the disclosure of information will work for or against the patient. Where families, spouses, parents or children are involved it is wise to spell out the standards of confidentiality in the earliest stages of treatment. Even when the decision is to withhold all information, the family should not be entirely ignored but should be helped with whatever support is appropriate, for the emotional state of the family often directly affects the patient and his treatment.
When schools become the requesting third parties the decision to disclose also rests on whether such disclosure works for or against the patient. Often a school will modify its program in a therapeutic way if given appropriate information by the psychiatrist. On the other hand, there is the complication that such information may find its way into permanent school records where it will eventually become out of date and may be available to personnel who do not have the benefit of direct consultation with the psychiatrist. The fate of information once it is released to a third party is a serious problem, and efforts must be made to see that confidential information released to one third party remains confidential with respect to other third parties.
Employers become third parties requesting information in certain occupations where emotional health is felt to be significant in carrying out responsibilities. Generally, psychiatric examination to determine suitability for employment should be carried out independently of treatment and the treating psychiatrist. The judgment in such employment situations should rest on observable job behavior and not on the fact that the employee is in treatment. The long run advantage is to the employer as well as the employee if indicated treatment is sought early, and it is counter-productive for both if the treatment process stigmatizes an employee or makes him vulnerable to dismissal.
The second way in which an employer may request information about an employee's treatment comes from the fact that employers often pay a part or all of the employee's insurance premium. The employer, therefore, needs actuarial information about his employees' use of the insurance program so he may have the data from the insurance carrier that determines premiums to be paid and the cost benefit of his employer insurance program. In such cases information given to employers (or labor unions) should be in the aggregate and should never reveal specific information about an individual employee. Such aggregate data is sufficient for the purposes required and release of any more detailed information would constitute an unwarranted abrogation of confidentiality.
This brings us to the most important third party, the insurance company. Persons enroll in insurance programs to protect their future health and welfare. It therefore follows that the insurance company ought to do nothing which would defeat this aim. On the other hand, the insurance company has the right and some might even argue the responsibility to see that claims are justified and appropriate. It should do so, however, always in a way which will not undermine the patient's health and welfare. Any patient receiving care from any system of paying should have access to all medical services without jeopardizing privacy or confidential relationships with physicians.
Some insurance contracts limit coverage to certain illnesses or certain time periods, therefore insurance companies are entitled to information about patients which is pertinent to these areas. Thus it is necessary in many contracts to demonstrate that an illness did not exist prior to the effective date of the policy. Usually an indication that the patient had an illness which needs treatment is required. To substantiate the type and frequency of treatment given it may be necessary to give some information indicating the general degree of impairment the patient suffers unless treated. This information may be needed too for billing purposes. Finally, the fact that the patient suffers from a psychiatric condition covered by the contract may need to be stated. But in no case should a patient stricken by a condition be penalized because he has added a “burden" to the group. Furthermore, when the cost accounting of a group is made the individual's privacy should not be compromised and all data should be reported in the aggregate. The insurance companies' legitimate right to some information concerning patients is circumscribed. The precise diagnosis and even current "degree of disability" is probably not germane to the policy needs nor helpful to the insurance industry in answering the questions raised, when they follow the general medical model for actuarial purposes. They can usually be replaced by a general category of functional impairment. No information should be given which could in any way be used against the patient. Communications by psychiatrists with an insurance company should be directly with its physician representative, thus subjecting the receiving physician to the same ethical standards of confidentiality the treating physician has. If eligibility to enroll in an insurance program is in question, as it often is in life insurance and some health insurance, the matter should be determined by an examination designed for that purpose, and not by information from the treating psychiatrist.
Any national health insurance program should include strict safeguards of confidentiality built into any data collection or storage system. We must assure that the minimum necessary demographic and health information about the individual be separated from national health statistics. Accessibility to this data must be sharply and carefully limited.
One special sub-category of confidentiality is that of privilege. Here the third party is the court and special legal parameters apply. While it is not necessary here to go into great detail about privilege, we do feel that many of the same principles governing confidentiality also apply to privilege. (For clarification of the distinction between confidentiality and privilege see "Position Statement on Guidelines for Psychiatrists: Problems in Confidentiality", American Journal of Psychiatry, 126:10, 187-193, April, 1970.)
When information is requested it is the psychiatrist's responsibility to explore with the patient the risks of breaking or relinquishing the privilege, and he should discuss the nature of the material which might be divulged. When asked to testify the psychiatrist must be one of the agents protecting the patient's best interests. If information is demanded and legal recourse has been exhausted, only that information specifically required should be revealed and no more. And we should as psychiatrists work for the establishment of privileged statutes which will maximally protect a patient's privacy and the confidentiality of their treatment.
From the foregoing some basic principles can be extracted. These are enumerated following.
DEFINITION OF PURPOSE
To determine the nature of problems threatening confidentiality between patients and physicians, particularly through demands of third party interests.
AREAS OF CONSIDERATION BY THE TASK FORCE
The Task Force on Confidentiality as Related to Third Parties (TFC) began conferences with Medical and Claims representatives of the insurance industry to study their legitimate needs for information and to examine with them the nature of psychiatric illness and treatment processes. Efforts were made in an attempt to reach an accord on the following aspects of this problem.
New Code System. One important achievement of the TFC was the formulation of a new code for reporting psychiatric conditions to third party agencies for health insurance claims. The TFC met in May, 1971, with various insurance agency representatives, including a committee of medical directors (Life Insurance Medical Directors of America, LIMDA) and the Health Insurance Council (HIC). As a result, a new reporting system was designed using a specific code aimed at fulfilling insurance agencies' needs while not revealing unnecessary information which could be misused or otherwise be damaging.
This new system of reporting was presented to the Council on Professions and Associations before being sent to all the District Branches in the U. S. and Canada for their examination and comment. Generally favorable and constructive suggestions were made, with the exception of a few that unrealistically advocated sending no information at all. Following discussion by the Council, the Reference Committee and the speaker of the Assembly of District Branches and representatives of the Health Insurance Council arrangements were made and are currently underway for an actual trial in the field. (A copy of the working code system is attached as Appendix B.)
Methods of Reporting to Insurance Companies. Much of the need for information by the industry is for the administration of the insurance contracts. Reimbursement of medical expenses and disability payments, etc. depend on the nature and detail of different insurance contracts. There may be certain exclusions, and the date of onset is also important. For instance, benefits usually are limited to