One of the cardinal principles that underline the relationship between a doctor and a patient is confidentiality. This forms the basis of the patient-doctor relationship. In the oath that must be taken at the initiation into the noble profession, the doctor thus avows: “I will respect the secrets confided in me, even after the patient has died” (The World Medical Association Declaration of Geneva). The trust of the patient enables him or her to provide the doctor with the information necessary for diagnosis and treatment. All medical associations have included the confidentiality clause in their codes of ethics.
An exception did arise when a doctor felt in a particular case, he was duty-bound to protect the society and give out vital information about a particular patient with or without the patient’s consent. The story goes thus;
An Englishman in the late 1970s shot four members of a neighbouring family and another neighbour, who had come to investigate the shooting. He then drove off in his car, throwing hand-made bombs as he did so. Later that day, he shot two more people. Five of the victims died of their injuries. The Englishman was diagnosed as suffering from paranoid schizophrenia, a severe mental illness. The illness involved vivid imaginations that he was being persecuted by his victims.
In the circumstances, the Englishman pleaded guilty to manslaughter on grounds of diminished responsibility and was convicted accordingly. He was taken to a top security mental hospital where he was to undergo a rehabilitation programme leading to discharge back into the community but on a recommendation of a doctor to the Secretary of State and/or the Mental Health Review Tribunal.
A few years later, the resident doctor treating the Englishman recommended his transfer to a less secure unit and ultimately his discharge. The doctor reported that the patient’s mental illness had been controlled by medication and had been stable for the previous two years. The Secretary of State declined to give permission on grounds that there was need for uttermost caution to be exercised in this case, bearing in mind the patients indiscriminate violence towards his victims. Not satisfied, the lawyers for the Englishman appealed to the tribunal. They hired an independent and distinguished consultant psychiatrist, Dr Egdell, to evalute the Englishman and make a report to the tribunal. Dr Egdell’s report did not favour the patient at all. The doctor, in his report, noted a striking lack of remorse even at a simple verbal level.
The doctor also noted that although the patient accepted medication, this appeared a move to avoid being labeled as a psychopath. The consultant also noted with concern the patient’s lifelong abnormal interest in home-made bombs that patient refers to as fireworks. Dr Egdell was of a strong view that the Englishman, was in fact a psychopath, still a danger to the community and should not be considered for a transfer to a less secure unit.
Upon receipt of Dr Egdell’s report, the lawyers did what they do best; keep the report under lock and key and withdraw the application to the tribunal. Dr Egdell, however, found out that his report did not reach the tribunal and the responsible medical director.
He then forwarded his report to the tribunal and the medical director, even after the Englishman’s lawyers strongly declined disclosure. The lawyers commenced proceedings against Dr Egdell for breach of his duty of confidence.
Judgment was entered in favour of Dr Egdell. In one of the judgments, it was stated “A doctor called upon to examine a (dangerous) patient owes a duty not only to his patient but also to the public. His duty to the public would require him to place before the proper authorities the result of his examination if, in his opinion, the public interest so required whether or not the patient instructed him not to”.
The judges also referred to the provisions of Professional Confidence under the Medical Act where the following exceptions favour disclosure;
• If the patient or his legal adviser gives written and valid consent.
• Confidential information may be shared with other medical practitioners who participate in the clinical management of the patient.
• The doctor may, in particular circumstances, give, in confidence, information regarding a patient’s health to a close relative. This occurs when the doctor believes that it is undesirable on medical grounds to seek the patient’s consent.
• In exceptional circumstances, the doctor may disclose information to a third party other than a relative if it is in the best interest of the patient.
• Information may be disclosed to the appropriate authority if so demanded by law.
• If the doctor is directed to disclose information by a judge or other presiding officer before whom he is giving evidence.
• Disclosure may also be justified on the ground that it is in the public interest.
• Information may also be disclosed for the purpose of a medical research if approved by an ethical committee.