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BMJ No 7124 Volume 316 Education and debate Saturday 3 January 1998
Ethical debateChild sexual abuse: when a doctor's duty to report abuse conflicts with a duty of confidentiality to the victim Confidentiality may be overvaluedAnthony S KesselWith a disturbingly high prevalence of physical and sexual abuse in the community, it is not uncommon for doctors to become involved in situations of the kind described. Here, the paediatrician has presented two possible courses of action - to report the matter, thereby breaching confidentiality, or to maintain confidentiality by not disclosing the incident. Legally, either option is defensible. This is reflected in the General Medical Council's guidelines.(1) These advise that confidentiality should be respected, but that disclosure "may be necessary in the public interest where a failure to disclose information may expose the patient, or others, to risk of death or serious harm." Information should then be disclosed "promptly to an appropriate person or authority." What is of particular relevance to this case is the statement in the guidelines that in some circumstances disclosure may be "necessary for the prevention or detection of a serious crime."(2) However, the law and codes of conduct inform only partly the moral deliberation that should precede any action that is taken.(3) Two particular elements of this case stand out, each of which is central to the ethical analysis. Firstly, the victim is no longer a patient and, secondly, it is the victim rather than the perpetrator who is confessing to the doctor. At this stage, the relationship between the woman and her former doctor could not be considered a therapeutic one, although it remains professional. Does the doctor have a duty to respect confidentiality in this kind of relationship? To answer this it is important to understand the moral foundations of confidentiality within the doctor-patient relationship. In terms of utilitarian doctrine, envisage a society without trust or honesty and then extend this to the healthcare domain. The consequences for patient care are obvious. But today there is a tendency to overvalue confidentiality. This has arisen through the influence of bioethics (its emphasis on principles and, especially, respect for patient autonomy) together with somewhat anachronistic medical codes which still imbue strongly Western medical culture.(4) In the professional relationship illustrated here a duty of
confidentiality does exist, but it is less strong than that in a
therapeutic relationship. Any such duty diminishes further when
considered in the context of historical overstatement.(5)
Weighed against this, the doctor, like anyone else, also has duties to
society that include, in this case, the perpetrator's family, the
neighbourhood, and the more nebulous concept of society in general. The second point, that somewhat unusually it is the victim rather
than the perpetrator of a crime confessing to the doctor, highlights
some important practical issues. The woman claimed that she wanted to
see the notes to find out if the sexual abuse had been documented. To
make the effort without wanting to take the matter further simply does
not make sense. Surely this is a plea for support as well as justice?
If, however, the woman really refuses to become embroiled in further
investigations, there is little likelihood of any legal case being
brought against her abuser.
The doctor has more choices than the two described, but more
information is needed before any decision can be made. Disclosure may
be the best course in view of the wider considerations; thus it depends
on what further information yields.
Epidemiology Unit,
Correspondence to: 57a Woodland
Rise,
email: a.kessel@lshtm.ac.uk
References
1 General Medical Council. Duties of a doctor
(confidentiality). London: G
2 Brazier M. Medicine, patients and the law.
London: Penguin, 1992:44-59.
3 Seedhouse D, Lovett L. Practical medical
ethics. Chichester: Wiley, 1992.
4 Davis R. The principlism debate: a critical overview. J
Med Philosophy 1995;20:85-105.
5 Van Heteren G, Kessel A. Beyond the "two-worlds"
perspective in medicine. Health Care Analysis
1995;3:353-7.
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