J Relig Health DOI 10.1007/s10943-013-9795-x ORIGINAL PAPER
Analysis of Medical Confidentiality from the Islamic Ethics Perspective Saeid Nazari Tavaokkoli • Nasrin Nejadsarvari • Ali Ebrahimi
Springer Science+Business Media New York 2013
Abstract Confidentiality is one of the old rules of the medical profession. While emphasizing the necessity of confidentiality in religious teachings, disclosure of other’s secrets to commit sin deserves punishment hereafter known. Today, progress in medical science and invention of new diagnostic and therapeutic procedures, as well as the extent of information and disclosure of the secrets of the patients, have provided more than ever. After explaining the concepts and principles of confidentiality in medical ethics, the Islamic-oriented Virtue Ethics, in a comparative review, share the differences in these two sets of ethical review and explain the issue of confidentiality. In professional medical ethics, only the behaviors of health staff are evaluated and moral evaluation of the features cannot be evaluated, but in Islamic ethics, the moral evaluation of the features that are sensual, confidentiality is more stable, without any external supervision will maintain its efficiency. Keywords
Medical ethics Confidentiality Islam Patients Physicians
Introduction Efficient communication with patients is an art of a skilled physician (Lloyd and Bor 2004). This communication is based on building the patient’s trust in physician, and following the confidentiality guidelines is especially important in building this trust (Johnson and Johnson 2007). Medical confidentiality has been among the main principles of medicine for longtime and has been respected by the physicians (Higgins 1989). In the
S. N. Tavaokkoli Faculty of Theology, Tehran University, Tehran, Iran N. Nejadsarvari (&) Shaheed Beheshti and Tehran University of Medical Sciences, P. O. Box 1436614313, Tehran, Iran e-mail: [email protected]; [email protected] A. Ebrahimi Plastic Surgery Ward and Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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fourth century BC, confidentiality was mentioned in Hippocratic Oath as an important cornerstone in patient–physician communication, which states, ‘‘That whatsoever I shall see or hear about the lives of my patient that is not fitting to be spoken. I will keep in confidence.’’ Since then, confidentiality as the common main part of medical oaths and national and international medical ethics codes have been considered and followed (Anonymous 2012). If the patient does not trust the physician, he will not go on a visit, or if he does, he will not give adequate description of his condition. Subsequently, the physician cannot make a correct diagnosis, and the treatment does not go to its right path (Johnson and Johnson 2007). The result of this vicious cycle would be pain and agony of patients and complications of wrong treatments. In addition, breach of confidentiality can result in ethical dilemmas for the patients, and sometimes the suffering resulting from this process is greater than the physical pain itself, and it is not even reversible (Weber 1992). Breach of confidentiality in the past was mostly in the form of discussing cases openly in public like in the elevator or in a restaurant with people who were not involved in the case (Johnson and Johnson 2007). However, at present, by the advancements in the field of medicine and development of contemporary broadcasting, this problem has become bigger (Sade 2010). Human genetic studies (Beauchamp and Childress 2009), carelessness of the media, electronic registry of patients’ files, transporting patient’s information through email and internet network, telemedicine (1998), evaluation of patients’ records by the personnel and hospital staff not involved in the case, preparing slides from hospitalized patients for educational purposes, and educational group rounds in teaching hospitals are among the situations that may result in breach of patient–physician confidentiality (Johnson and Johnson 2007). At present, secular medical ethics try to eliminate such ethical obstacle but have had temporary result, and these problems still exist. Islam has greatly emphasized on secrecy and confidentiality of information (Abdullah 2012). This study discusses the concept of confidentiality of information in medical ethics and accredited Islamic literature and evaluates its pros and cons from the Islamic point of view.
Discussion Medical Confidentiality Confidentiality is derived from the term confidence and is defined as keeping one’s secret (http://www.thefreedictionary.com/confidentiality). In medicine, the term confidentiality means to keep patient’s information private and not to share or disclose them to a third party without patient consent (2009). According to Beauchamp and Childress, confidentiality means not disclosing a secret that has once been disclosed in a private conversation. In patient–physician relationship, the patients rightfully expect the physician to keep their secret and not to disclose it without their consent. In another study, they define confidentiality as a Frank unspoken obligation not to disclose patients’ information (verbally or non-verbally) without their consent to a third party (Beauchamp and Childress 2009). Medical secret is patient’s confessions about his previous conditions, illnesses, family history and all the information that the patient shares with the physician in response to his questions or examinations and the final diagnosis and data that the physician gains as the result of him going into patient’s family circle (Johnson and Johnson 2007).
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Breach of patient–physician confidentiality means to share patient’s information with a third party in some special situations (Johnson and Johnson 2007). Patient–physician confidentiality is the cornerstone of medical ethics. It has been a part of all ancient oaths. In the fourth century B.C., it has been mentioned as a sacred responsibility in Hippocratic Oath. ‘‘That whatsoever I shall see or hear about the lives of my patient that is not fitting to be spoken; I will keep in confidence’’ (Anonymous 2012). Monpollier oath takes confidentiality to the next level and emphasizes on the patients’ privacy stating that my eyes will not see the secrets of the houses that I am going to visit, and my tongue will not reveal the secrets that I have been told and my behavior will never facilitate crime and corruption. Also, Ahwazi in his Pandnameh talks about this subject and states that the physician has to keep patients’ secrets and not to disclose them in front of anybody because many patients keep their illness from their parents or relatives and only discuss it with their physician (like menstrual cramps, hemorrhoids, etc.); therefore, physicians have to be extremely secretive about their patients’ illnesses. Assaph is another oath in medical ethics emphasizing on the importance of confidentiality in medicine (Higgins 1989; Post 2004). This subject has been among the physicians’ duties for long and was later included in the national and international medical ethics literature and conventions among which we can name the Geneva Convention (1948/1994) which emphasizes on confidentiality even after patient’s death (Johnson and Johnson 2007). According to the 4th principle of American Medical Association Code of Medical Ethics, the physician is obliged to follow patient–physician confidentiality (Anonymous 2012). In medical guidelines, especially in research projects, confidentiality plays an important role. Reasons why physicians are obliged to be confidential: 1. Utilitarian aspects: Breach of confidentiality results in patients losing faith and trust to their physicians. Trust is the cornerstone of patient–physician relationship, and if this trust is breached, the patient will not cooperate with the physician and does not provide him with the necessary information or does not let the physician to do a complete workup. As a result, the physician will not be able to correctly diagnose the illness, and therefore, treatment will not be possible. Subsequently, the patient is not perfectly treated (Beauchamp and Childress 2009; Jones 2003). 2. Confidentiality the cause of preserving patients’ autonomy: According to this justification, personal information about every individual is a private matter and cannot be disclosed to anyone else without their consent. Thus, only the patient has the right to decide in this regard, and therefore, obtaining a written informed consent is necessary before sharing patients’ personal, clinical and paraclinical information (Beauchamp and Childress 2009; Ro¨seler 2005). 3. Confidentiality protects patients’ privacy: Although confidentiality and privacy are not synonyms, invading someone’s privacy is a prerequisite for breach of confidentiality. Confidentiality is to keep patients’ informational privacy. Privacy is a subject in sociological, philosophical and social theories, and preserving it is necessary for an independent and free life that every individual is entitled to have. Not respecting patients’ privacy may have adverse consequences for the society and result in severe social and familial problems (Beauchamp and Childress 2009; Ro¨seler 2005). The international Guidelines on HIV/ AIDS human rights in 2006 condemned the mandatory HIV test due to the invasion of privacy and obliged the governments to keep the test results of HIV patients confidential (Anonymous. International guideline on HIV/AIDS human rights 2006). Breach of medical confidentiality in medicine: At present, in medical center’s, patients’ information is easily shared with others without patients’ consent. Medical personnel do not know how to keep patients’ information confidential, and this is the main cause of the
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confidentiality breach. In the past, most pioneers in medical ethics were supporting absolute confidentiality. Hippocratic Oath and Geneva’s convention made no exception for confidentiality and believed that it should not be breached under any circumstances. However, some believe that in some special situation’s, relative breach of confidentiality is acceptable, and in modern medical ethics, confidentiality is not absolute (Post 2004). Therefore, in cases like consent from the patient, reporting communicable diseases to the respective centers, report of birth or death, testifying in court, patient’s decision on committing a crime, revealing a secret for self-protection and protecting others, breach of confidentiality is not only accepted but necessary (General medical council and 2012). However, in the mentioned cases’, breach of confidentiality is only accepted to the extent that is necessary for preventing the expected damage, and the secret should only be revealed to those it may concern. This way, the lowest possible damage is done to the patient (Post 2004). Confidentiality is not absolute, and under special circumstances, some secrets can be revealed. The famous Tarasoff study is an example of someone becoming the victim of absolute confidentiality of a physician (Beauchamp and Childress 2009). The physician should keep a balance between having the permission to reveal a secret and obligation to do so and logically prevent the maximum damage. Confidentiality from the Islamic Ethics Point of View Confidentiality in Islamic ethics is defined as not disclosing a secret. Confidentiality also known as keeping a secret is an important concept in Islam and is a highly emphasized obligation. The one who does not obey and disclose someone’s secret has done a major sin and will be subjected to severe punishment (Majma-ol-Bahrain 1994). Mola Mehdi Naraghi in his book ‘‘Jame-o-Saadat’’ mentions that a secret can sometimes be a flaw and sometimes not. However, revealing a secret, whether a flaw or not, is an invasion of privacy. Whether it is out of animosity, financial issues or just vice, it is an unacceptable act (Jame-o-Saadat 2009). In many religious resources, breach of confidentiality is defined as invading safekeeping (Jame-o-Saadat 2009). Disclosing someone’s secret is forbidden in Islam because it hurts people and creates distrust. In Islam, secret is divided among three categories: self’s secret, others’ secret and religious secret. Keeping others’ secrets has been emphasized in religious books. Muhammad the prophet states that if someone keeps his Muslim brother’s secret god will keep his secrets in this world and in the afterlife. Islamic confidentiality can be discussed in 3 domains of military, religious or politics and ethical. In military, confidentiality is to keep the military secrets from the enemy. Military confidentiality in Islam is so important that breaching it is equal to betrayal of god and Prophet Muhammad. As we read in the Quran: ‘‘O ye who believe and do not betray Allah and the Prophet.’’1 Political and religious confidentiality is similar to ‘‘Taghiah’’ and is used to achieve ultimate goals. In ‘‘Taghiah’’ by the apparent calmness, the enemy is deceived but one secretly continues fighting his enemy. Muhammad the prophet states that the one who quits Taghiah is similar with the one who quits praying.
1
Alanfal 27/8.
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Ethical confidentiality is to keep the secrets of Muslim brothers. Sometimes the flaws are considered a secret. Therefore, confidentiality plays a significant role in respecting one’s position within the society and does not allow a sin to become popular and routine. Islam emphasizes on keeping the sins as secret, and revealing others’ sin in Islam is considered a major sin. In Islam, there is obligation upon a person to be confidential. In Holy Quran, trusteeship is one of the best examples of fidelity.2 So trusteeship in the Holy Quran is as one of the outstanding traits of believers, all people are committed to preserving and discharging integrity, because their secret is immaterial integrity. According to the holy Quran: ‘‘Allah dothed command you to render back your Trusts to those to whom they are due; And when ye judge between man and man, that ye judge with justice: Verily, how excellent is the teaching which he give you! For Allah is He Who hearth and set all things’’(Al-Nesa 58) and also: ‘‘O ye that believe! Betray not the trust of Allah and the Messenger, nor misappropriate knowingly things entrusted to you’’(Al-Anfal 8/27). Reasons why people are obliged to be confidential: 1. Benefits of secrecy: Confidentiality as the saving human life: the first and main human interest is to save human lives and protect the right to life of the population, naturally, takes precedence over other human rights. Taghiah is a political and ideological confidentiality that is necessary not only because of the helplessness but also it is important to shield people against the enemy. Prophet muhammad explained the importance of Taghiah: ‘‘It is like someone who leaves the Taghiah is similar to person that leaves the prayer (Bahar-ol-Anvar 2012a).’’ • The reason for people’s happiness beyond this life and the afterlife: According to Imam, Ali’s happiness beyond this life and in the afterlife is in two things secrecy and friendship with good people (Bahar-ol-Anvar 2012b). According to prophet Muhammad: Keeping a trust results in abundance of and betrayal results in poverty. • Confidentiality, respecting one’s right to make a decision: No one is allowed to invade someone’s privacy in Islam, and no one should disclose one’s secret to a third party without his consent. Confidentiality, Respect others’ privacy: According to the holy Quran: ‘‘O ye who believe! Enter not houses other than your own, until ye have asked permission and saluted those in them: that is best for you, in order that ye may heed (what is seemly). If ye find no one in the house, enter not until permission is given to you: if ye are asked to go back, go back: that makes for greater purity for yourselves: and Allah knows well all that ye do’’ (Al-Noor 24/27,28). 2. Confidentiality in the society results in the followings: • Protecting people’s personality and position within the society: This is especially important when the secret is someone’s flaw. By being confidential in such cases, the person’s position and social personality will be saved. It is also among the god’s characteristics not to disclose his creatures’ secrets and flaws. Thus, the Quran, slander, and the absence of defects and to prohibit others stressed the need to preserve the dignity of the believer.
2
Al-Baghareh 2-100, Al-Asra 17-34, Al-Momenoon 23-8, Al-Maarej 70-32.
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• Developing trust for the society: Islam is social religion, and even prayers and fasting too have social aspects. Islam emphasizes on the role of individual within a society and his responsibilities and duties to the community. Trust is an important issue in a society and presence of distrust in a society will damage the people’s quality of life. • Exceptions. Although the Quran and hadith of the view is a great emphasis on the need to hide behind, but God forbids that all the gains on disposal of interest is the corruption, so in this case, also some exceptions in violation of secrecy in religious sources have mentioned. In some cases, it is acceptable if one discloses someone else’s secret. For example, in a process of an investigation, when someone’s life or well-being is in danger or for the sake of the community health and safety, one is allowed to disclose a secret. Furthermore, when appointing a position to a person, it is necessary to do a background check and people are responsible to share any relevant information about the person of interest. It is also important to disclose the secret to the right person. According to the holy Quran: ‘‘O ye who believe! Take not into your intimacy those outside your ranks, They will not fail to be corrupt you; They only desire your ruin; Rank hatred has already appeared from their mouths, What their hearts conceal is far worse, We have made plain to you the Signs, if ye have wisdom’’ (AL-Imran 118).
Critical Review At present, by the advancements in the field of medicine, human genetic studies, telemedicine and electronic registry of patients’ files, the importance of confidentiality becomes more and more apparent. Not paying enough attention to this issue can have adverse consequences. The authorities have made efforts to overcome this obstacle through holding medical ethics educational courses, seminars, workshops and national and international congresses. National and international congresses also failed to eradicate this ethical dilemma. This study demonstrated that confidentiality is similarly important in both the medical ethics and Islamic ethics. Confidentiality is the first step in developing trust in patient–physician relationship (Anonymous). The physician should not disclose patients’ information to a third party without their consent. This is especially important when the patient is suffering from sexually transmitted diseases, mental illnesses or addiction because disclosing such information can significantly affect patient’s life. Informing the spouse of an HIV positive patient is a major subject of discussion and controversy in this respect and there is no consensus in this respect (Njozing et al. 2011). In Islamic ethics, breach of confidentiality is permitted only by Estizan (consent). Although the breach of confidentiality is prohibited from both Islamic and medical ethics, but they accepted that confidentiality is not absolute. Studies have indicated that physicians who have religious beliefs have been more careful with confidentiality issues (Lawrence et al. 2011). Medical ethics are being taught in medical universities. However, personality and religious views of physicians also play an important role in this regard. Medical ethics now follow a secular view and only focus upon the behavior of physicians in the work environment. They do not address the inner personality and belief of physicians. A religious person knows that there are consequences for every action and therefore are more careful in his actions. Islamic ethics and human behavior both consider faith-based soul, and ego
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states the most important factor for the formation of intentions and behavior is known. Late chamber to explain is the importance of this issue ‘‘correcting unit of man as the most difficult the intention is the sensual mode.’’ Today medical ethics teaching only assess behavior and do not evaluate motives, so it is necessary to external control. On the other hand, soul circuit of Islamic ethics consider motives, and so with eliminating sprit challenges makes modification of behavior without any external control.
Conclusion Confidentiality is the secret of the fiduciary patient, and physician is ethically obligated to maintain it. Failure to observations is considered as a betrayal of the right to autonomy and privacy of the patient, also it can result in mistrust and lack of effective communication and intimacy between patients and their doctors. Islamic morality not only cannot be removed from the dignity of the individual and social lifestyle of people. Rather, our study reinforces the suspicion that a religious attitude is a major factor in considering further medical ethics and makes physicians to follow ethical guidelines more than others. Islam has a complete set of guidelines regarding ethical issues, which have to be taught to medical students. Confidentiality requires practice and education and training in this regard are not enough. Therefore, education and practice in this respect should be started in high school and before initiation of medical training.. Finally, Confidentiality is not absolute and in some situations, relative confidentiality has to be followed. Conflict of interest None declared.
References Abdullah, F. (2012). Teaching islamic ethics and ethical training: benefiting from emotional and spiritual intelligence. International Journal of Humanities and Social Science, 2(3), P224–P230. Anonymous. The Hippocratic oath. http//en.wikipedia.org/wiki/Hippocratic-oath. (Accessed 2012). Anonymous. (2012). American Medical Association. AMA Code of Medical Ethics.Principles of medical ethical ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medicalethics/principles-medical-ethics.page. Accessed 2012. Anonymous. (2012). Medical Professionalism in the New Millennium: A Physician Charter. http://pdffinder. net/Medical-Professionalism-in-the-New-Millennium:-A-Physician-Charter.html. (Accessed 2012). Anonymous.International guideline on HIV/AIDS human rights 2006 consulidation version. (2012). http:// data.unaids.org/publication/IRC.pub07/jc1252-internguidelines_en.pdf. Accessed 2012. Anonymous. General medical council, Confidentiality. (2012). http://www.gmc-uk.org/static/documents/ content/Confidentiality_0910.pdf. Accessed 2012. Bahar-ol-Anvar, M. M. B. (2012a). Vol 75, p. 412. Tehran: Almaktaba Eslamia. Bahar-ol-Anvar, M. M. B. (2012b). Vol 78, p. 239. Tehran: Almaktaba Eslamia. Beauchamp, T., & Childress, J. (2009). Principles of biomedical ethics ( (6th ed., pp. 302–309). New York: Oxford University Press. Higgins, G. L. (1989). The history of confidentiality in medicine. Canadian family Physician, 35, 921–926. Jame-o-Saadat, N. M. (2009). 2nd ed., Vol. 2, pp. 123–124, 214–222. Qom: Qaem Publications. Johnson, A. G., & Johnson, P. V. (2007). Making sense of medical ethics. Oxford: Oxford university press. p. 101. Jones, C. (2003). The utilitarian argument for medical confidentiality: a pilot study of patients views. Journal of Medical Ethics, 29, 348–352. Lawrence, R., Rasinsli, K., Yon, J., & Curlin, F. (2011). Adolescents, contraception and confidentiality: a national survey of obstetrician–gynecologists. Conteraception, 84(3), 259–265.
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J Relig Health Lloyd, M., & Bor, R. (2004). Communication skills for medicine (2nd edn ed., p. 43). Churchio livingstone: London. Majma-ol-Bahrain, T. F. (1994). In Seyed Ahmad Hosseinff (Ed.) (3rd ed., Vol. 3, pp. 328–329) Tehran. Mosby’s Medical Dictionary. (2009). 8th ed. 2009, Elsevier. http://medical-dictionary.thefreedictionary. com/confidentiality. Njozing, B., Edin, K., Sebastia´n, M., Hurtig, A. (2011). If the patients decide not to tell what can we do?TB/HIV counsellors dilemma on partner notification for HIV.BMC int health right; vol 11, pp. 3–11. Post, S. G. (2004). Encyclopedia of bioethics, 3rd edn. Michigan: Macmillan reference. 494–496, 2633–2716. Ro¨seler, B. (2005). The value of privacy (Trans R.D.V Glasgow). Cambridge: Polity Press, p 50. Sade, R. M. (2010). Breaches of health information: Are electronic records different from paper records?. The Journal of Clinical Ethics 21(1) (Spring 2010): 39–41.http://academicdepartments.musc.edu/ humanvalues/pdf/Breaches.ofhealth.information.pdf. The free dictionary by farlex. http://www.thefreedictionary.com/confidentiality. The legal and ethical aspects of telemedicine. (September 1998). 4: Product liability and jurisdictional problems. J Telemed Telecare. 4, 132—139; From http://jtt.rsmjournals.com/content/3/4/179.short. Weber, L. J. (1992). Resolving ethical dilemmas about privacy and confidentiality. Guidelines for decision making. Clinical Laboratory Management Association. 1992 Nov–Dec; 6(6), 514–516, 518–520. from http://www.ncbi.nlm.nih.gov/pubmed/10128838.
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Analysis of Medical Confidentiality from the Islamic Ethics Perspective Saeid Nazari Tavaokkoli • Nasrin Nejadsarvari • Ali Ebrahimi
Springer Science+Business Media New York 2013
Abstract Confidentiality is one of the old rules of the medical profession. While emphasizing the necessity of confidentiality in religious teachings, disclosure of other’s secrets to commit sin deserves punishment hereafter known. Today, progress in medical science and invention of new diagnostic and therapeutic procedures, as well as the extent of information and disclosure of the secrets of the patients, have provided more than ever. After explaining the concepts and principles of confidentiality in medical ethics, the Islamic-oriented Virtue Ethics, in a comparative review, share the differences in these two sets of ethical review and explain the issue of confidentiality. In professional medical ethics, only the behaviors of health staff are evaluated and moral evaluation of the features cannot be evaluated, but in Islamic ethics, the moral evaluation of the features that are sensual, confidentiality is more stable, without any external supervision will maintain its efficiency. Keywords
Medical ethics Confidentiality Islam Patients Physicians
Introduction Efficient communication with patients is an art of a skilled physician (Lloyd and Bor 2004). This communication is based on building the patient’s trust in physician, and following the confidentiality guidelines is especially important in building this trust (Johnson and Johnson 2007). Medical confidentiality has been among the main principles of medicine for longtime and has been respected by the physicians (Higgins 1989). In the
S. N. Tavaokkoli Faculty of Theology, Tehran University, Tehran, Iran N. Nejadsarvari (&) Shaheed Beheshti and Tehran University of Medical Sciences, P. O. Box 1436614313, Tehran, Iran e-mail: [email protected]; [email protected] A. Ebrahimi Plastic Surgery Ward and Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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fourth century BC, confidentiality was mentioned in Hippocratic Oath as an important cornerstone in patient–physician communication, which states, ‘‘That whatsoever I shall see or hear about the lives of my patient that is not fitting to be spoken. I will keep in confidence.’’ Since then, confidentiality as the common main part of medical oaths and national and international medical ethics codes have been considered and followed (Anonymous 2012). If the patient does not trust the physician, he will not go on a visit, or if he does, he will not give adequate description of his condition. Subsequently, the physician cannot make a correct diagnosis, and the treatment does not go to its right path (Johnson and Johnson 2007). The result of this vicious cycle would be pain and agony of patients and complications of wrong treatments. In addition, breach of confidentiality can result in ethical dilemmas for the patients, and sometimes the suffering resulting from this process is greater than the physical pain itself, and it is not even reversible (Weber 1992). Breach of confidentiality in the past was mostly in the form of discussing cases openly in public like in the elevator or in a restaurant with people who were not involved in the case (Johnson and Johnson 2007). However, at present, by the advancements in the field of medicine and development of contemporary broadcasting, this problem has become bigger (Sade 2010). Human genetic studies (Beauchamp and Childress 2009), carelessness of the media, electronic registry of patients’ files, transporting patient’s information through email and internet network, telemedicine (1998), evaluation of patients’ records by the personnel and hospital staff not involved in the case, preparing slides from hospitalized patients for educational purposes, and educational group rounds in teaching hospitals are among the situations that may result in breach of patient–physician confidentiality (Johnson and Johnson 2007). At present, secular medical ethics try to eliminate such ethical obstacle but have had temporary result, and these problems still exist. Islam has greatly emphasized on secrecy and confidentiality of information (Abdullah 2012). This study discusses the concept of confidentiality of information in medical ethics and accredited Islamic literature and evaluates its pros and cons from the Islamic point of view.
Discussion Medical Confidentiality Confidentiality is derived from the term confidence and is defined as keeping one’s secret (http://www.thefreedictionary.com/confidentiality). In medicine, the term confidentiality means to keep patient’s information private and not to share or disclose them to a third party without patient consent (2009). According to Beauchamp and Childress, confidentiality means not disclosing a secret that has once been disclosed in a private conversation. In patient–physician relationship, the patients rightfully expect the physician to keep their secret and not to disclose it without their consent. In another study, they define confidentiality as a Frank unspoken obligation not to disclose patients’ information (verbally or non-verbally) without their consent to a third party (Beauchamp and Childress 2009). Medical secret is patient’s confessions about his previous conditions, illnesses, family history and all the information that the patient shares with the physician in response to his questions or examinations and the final diagnosis and data that the physician gains as the result of him going into patient’s family circle (Johnson and Johnson 2007).
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Breach of patient–physician confidentiality means to share patient’s information with a third party in some special situations (Johnson and Johnson 2007). Patient–physician confidentiality is the cornerstone of medical ethics. It has been a part of all ancient oaths. In the fourth century B.C., it has been mentioned as a sacred responsibility in Hippocratic Oath. ‘‘That whatsoever I shall see or hear about the lives of my patient that is not fitting to be spoken; I will keep in confidence’’ (Anonymous 2012). Monpollier oath takes confidentiality to the next level and emphasizes on the patients’ privacy stating that my eyes will not see the secrets of the houses that I am going to visit, and my tongue will not reveal the secrets that I have been told and my behavior will never facilitate crime and corruption. Also, Ahwazi in his Pandnameh talks about this subject and states that the physician has to keep patients’ secrets and not to disclose them in front of anybody because many patients keep their illness from their parents or relatives and only discuss it with their physician (like menstrual cramps, hemorrhoids, etc.); therefore, physicians have to be extremely secretive about their patients’ illnesses. Assaph is another oath in medical ethics emphasizing on the importance of confidentiality in medicine (Higgins 1989; Post 2004). This subject has been among the physicians’ duties for long and was later included in the national and international medical ethics literature and conventions among which we can name the Geneva Convention (1948/1994) which emphasizes on confidentiality even after patient’s death (Johnson and Johnson 2007). According to the 4th principle of American Medical Association Code of Medical Ethics, the physician is obliged to follow patient–physician confidentiality (Anonymous 2012). In medical guidelines, especially in research projects, confidentiality plays an important role. Reasons why physicians are obliged to be confidential: 1. Utilitarian aspects: Breach of confidentiality results in patients losing faith and trust to their physicians. Trust is the cornerstone of patient–physician relationship, and if this trust is breached, the patient will not cooperate with the physician and does not provide him with the necessary information or does not let the physician to do a complete workup. As a result, the physician will not be able to correctly diagnose the illness, and therefore, treatment will not be possible. Subsequently, the patient is not perfectly treated (Beauchamp and Childress 2009; Jones 2003). 2. Confidentiality the cause of preserving patients’ autonomy: According to this justification, personal information about every individual is a private matter and cannot be disclosed to anyone else without their consent. Thus, only the patient has the right to decide in this regard, and therefore, obtaining a written informed consent is necessary before sharing patients’ personal, clinical and paraclinical information (Beauchamp and Childress 2009; Ro¨seler 2005). 3. Confidentiality protects patients’ privacy: Although confidentiality and privacy are not synonyms, invading someone’s privacy is a prerequisite for breach of confidentiality. Confidentiality is to keep patients’ informational privacy. Privacy is a subject in sociological, philosophical and social theories, and preserving it is necessary for an independent and free life that every individual is entitled to have. Not respecting patients’ privacy may have adverse consequences for the society and result in severe social and familial problems (Beauchamp and Childress 2009; Ro¨seler 2005). The international Guidelines on HIV/ AIDS human rights in 2006 condemned the mandatory HIV test due to the invasion of privacy and obliged the governments to keep the test results of HIV patients confidential (Anonymous. International guideline on HIV/AIDS human rights 2006). Breach of medical confidentiality in medicine: At present, in medical center’s, patients’ information is easily shared with others without patients’ consent. Medical personnel do not know how to keep patients’ information confidential, and this is the main cause of the
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confidentiality breach. In the past, most pioneers in medical ethics were supporting absolute confidentiality. Hippocratic Oath and Geneva’s convention made no exception for confidentiality and believed that it should not be breached under any circumstances. However, some believe that in some special situation’s, relative breach of confidentiality is acceptable, and in modern medical ethics, confidentiality is not absolute (Post 2004). Therefore, in cases like consent from the patient, reporting communicable diseases to the respective centers, report of birth or death, testifying in court, patient’s decision on committing a crime, revealing a secret for self-protection and protecting others, breach of confidentiality is not only accepted but necessary (General medical council and 2012). However, in the mentioned cases’, breach of confidentiality is only accepted to the extent that is necessary for preventing the expected damage, and the secret should only be revealed to those it may concern. This way, the lowest possible damage is done to the patient (Post 2004). Confidentiality is not absolute, and under special circumstances, some secrets can be revealed. The famous Tarasoff study is an example of someone becoming the victim of absolute confidentiality of a physician (Beauchamp and Childress 2009). The physician should keep a balance between having the permission to reveal a secret and obligation to do so and logically prevent the maximum damage. Confidentiality from the Islamic Ethics Point of View Confidentiality in Islamic ethics is defined as not disclosing a secret. Confidentiality also known as keeping a secret is an important concept in Islam and is a highly emphasized obligation. The one who does not obey and disclose someone’s secret has done a major sin and will be subjected to severe punishment (Majma-ol-Bahrain 1994). Mola Mehdi Naraghi in his book ‘‘Jame-o-Saadat’’ mentions that a secret can sometimes be a flaw and sometimes not. However, revealing a secret, whether a flaw or not, is an invasion of privacy. Whether it is out of animosity, financial issues or just vice, it is an unacceptable act (Jame-o-Saadat 2009). In many religious resources, breach of confidentiality is defined as invading safekeeping (Jame-o-Saadat 2009). Disclosing someone’s secret is forbidden in Islam because it hurts people and creates distrust. In Islam, secret is divided among three categories: self’s secret, others’ secret and religious secret. Keeping others’ secrets has been emphasized in religious books. Muhammad the prophet states that if someone keeps his Muslim brother’s secret god will keep his secrets in this world and in the afterlife. Islamic confidentiality can be discussed in 3 domains of military, religious or politics and ethical. In military, confidentiality is to keep the military secrets from the enemy. Military confidentiality in Islam is so important that breaching it is equal to betrayal of god and Prophet Muhammad. As we read in the Quran: ‘‘O ye who believe and do not betray Allah and the Prophet.’’1 Political and religious confidentiality is similar to ‘‘Taghiah’’ and is used to achieve ultimate goals. In ‘‘Taghiah’’ by the apparent calmness, the enemy is deceived but one secretly continues fighting his enemy. Muhammad the prophet states that the one who quits Taghiah is similar with the one who quits praying.
1
Alanfal 27/8.
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Ethical confidentiality is to keep the secrets of Muslim brothers. Sometimes the flaws are considered a secret. Therefore, confidentiality plays a significant role in respecting one’s position within the society and does not allow a sin to become popular and routine. Islam emphasizes on keeping the sins as secret, and revealing others’ sin in Islam is considered a major sin. In Islam, there is obligation upon a person to be confidential. In Holy Quran, trusteeship is one of the best examples of fidelity.2 So trusteeship in the Holy Quran is as one of the outstanding traits of believers, all people are committed to preserving and discharging integrity, because their secret is immaterial integrity. According to the holy Quran: ‘‘Allah dothed command you to render back your Trusts to those to whom they are due; And when ye judge between man and man, that ye judge with justice: Verily, how excellent is the teaching which he give you! For Allah is He Who hearth and set all things’’(Al-Nesa 58) and also: ‘‘O ye that believe! Betray not the trust of Allah and the Messenger, nor misappropriate knowingly things entrusted to you’’(Al-Anfal 8/27). Reasons why people are obliged to be confidential: 1. Benefits of secrecy: Confidentiality as the saving human life: the first and main human interest is to save human lives and protect the right to life of the population, naturally, takes precedence over other human rights. Taghiah is a political and ideological confidentiality that is necessary not only because of the helplessness but also it is important to shield people against the enemy. Prophet muhammad explained the importance of Taghiah: ‘‘It is like someone who leaves the Taghiah is similar to person that leaves the prayer (Bahar-ol-Anvar 2012a).’’ • The reason for people’s happiness beyond this life and the afterlife: According to Imam, Ali’s happiness beyond this life and in the afterlife is in two things secrecy and friendship with good people (Bahar-ol-Anvar 2012b). According to prophet Muhammad: Keeping a trust results in abundance of and betrayal results in poverty. • Confidentiality, respecting one’s right to make a decision: No one is allowed to invade someone’s privacy in Islam, and no one should disclose one’s secret to a third party without his consent. Confidentiality, Respect others’ privacy: According to the holy Quran: ‘‘O ye who believe! Enter not houses other than your own, until ye have asked permission and saluted those in them: that is best for you, in order that ye may heed (what is seemly). If ye find no one in the house, enter not until permission is given to you: if ye are asked to go back, go back: that makes for greater purity for yourselves: and Allah knows well all that ye do’’ (Al-Noor 24/27,28). 2. Confidentiality in the society results in the followings: • Protecting people’s personality and position within the society: This is especially important when the secret is someone’s flaw. By being confidential in such cases, the person’s position and social personality will be saved. It is also among the god’s characteristics not to disclose his creatures’ secrets and flaws. Thus, the Quran, slander, and the absence of defects and to prohibit others stressed the need to preserve the dignity of the believer.
2
Al-Baghareh 2-100, Al-Asra 17-34, Al-Momenoon 23-8, Al-Maarej 70-32.
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• Developing trust for the society: Islam is social religion, and even prayers and fasting too have social aspects. Islam emphasizes on the role of individual within a society and his responsibilities and duties to the community. Trust is an important issue in a society and presence of distrust in a society will damage the people’s quality of life. • Exceptions. Although the Quran and hadith of the view is a great emphasis on the need to hide behind, but God forbids that all the gains on disposal of interest is the corruption, so in this case, also some exceptions in violation of secrecy in religious sources have mentioned. In some cases, it is acceptable if one discloses someone else’s secret. For example, in a process of an investigation, when someone’s life or well-being is in danger or for the sake of the community health and safety, one is allowed to disclose a secret. Furthermore, when appointing a position to a person, it is necessary to do a background check and people are responsible to share any relevant information about the person of interest. It is also important to disclose the secret to the right person. According to the holy Quran: ‘‘O ye who believe! Take not into your intimacy those outside your ranks, They will not fail to be corrupt you; They only desire your ruin; Rank hatred has already appeared from their mouths, What their hearts conceal is far worse, We have made plain to you the Signs, if ye have wisdom’’ (AL-Imran 118).
Critical Review At present, by the advancements in the field of medicine, human genetic studies, telemedicine and electronic registry of patients’ files, the importance of confidentiality becomes more and more apparent. Not paying enough attention to this issue can have adverse consequences. The authorities have made efforts to overcome this obstacle through holding medical ethics educational courses, seminars, workshops and national and international congresses. National and international congresses also failed to eradicate this ethical dilemma. This study demonstrated that confidentiality is similarly important in both the medical ethics and Islamic ethics. Confidentiality is the first step in developing trust in patient–physician relationship (Anonymous). The physician should not disclose patients’ information to a third party without their consent. This is especially important when the patient is suffering from sexually transmitted diseases, mental illnesses or addiction because disclosing such information can significantly affect patient’s life. Informing the spouse of an HIV positive patient is a major subject of discussion and controversy in this respect and there is no consensus in this respect (Njozing et al. 2011). In Islamic ethics, breach of confidentiality is permitted only by Estizan (consent). Although the breach of confidentiality is prohibited from both Islamic and medical ethics, but they accepted that confidentiality is not absolute. Studies have indicated that physicians who have religious beliefs have been more careful with confidentiality issues (Lawrence et al. 2011). Medical ethics are being taught in medical universities. However, personality and religious views of physicians also play an important role in this regard. Medical ethics now follow a secular view and only focus upon the behavior of physicians in the work environment. They do not address the inner personality and belief of physicians. A religious person knows that there are consequences for every action and therefore are more careful in his actions. Islamic ethics and human behavior both consider faith-based soul, and ego
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states the most important factor for the formation of intentions and behavior is known. Late chamber to explain is the importance of this issue ‘‘correcting unit of man as the most difficult the intention is the sensual mode.’’ Today medical ethics teaching only assess behavior and do not evaluate motives, so it is necessary to external control. On the other hand, soul circuit of Islamic ethics consider motives, and so with eliminating sprit challenges makes modification of behavior without any external control.
Conclusion Confidentiality is the secret of the fiduciary patient, and physician is ethically obligated to maintain it. Failure to observations is considered as a betrayal of the right to autonomy and privacy of the patient, also it can result in mistrust and lack of effective communication and intimacy between patients and their doctors. Islamic morality not only cannot be removed from the dignity of the individual and social lifestyle of people. Rather, our study reinforces the suspicion that a religious attitude is a major factor in considering further medical ethics and makes physicians to follow ethical guidelines more than others. Islam has a complete set of guidelines regarding ethical issues, which have to be taught to medical students. Confidentiality requires practice and education and training in this regard are not enough. Therefore, education and practice in this respect should be started in high school and before initiation of medical training.. Finally, Confidentiality is not absolute and in some situations, relative confidentiality has to be followed. Conflict of interest None declared.
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