SIR

I would like to acknowledge with regret that my sentence, of which Ms Stevens quotes half, is convoluted. A book review¹ is necessarily condensed and perhaps if it creates a problem it is best to read the book. But, in the complex legal, moral and ethical dilemmas arising in subjects such as confidentiality, it is highly dangerous to take half a sentence out of context (and I note that Ms Stevens does this to Maureen Marks's review² also) and use it to discuss a separate agenda, ie secrecy within the National Health Service (NHS).

I would draw Ms Stevens's attention to another book review³ of mine, or more wisely, to the book itself. Counselling, Psychotherapy and the Law, by Peter Jenkins, published in 1997 by Sage, in London, usefully separates out two opposite situations. There are those situations in which the therapist is custodian of confidential information and has to decide whether in certain circumstances, which are precisely defined, there are grounds for disclosure. Then there are those situations, where external agencies are demanding disclosure. This might be a legal demand but can be extended to include a patient's wish to see his or her own records, legally the property of the relevant trust in the NHS. “It is surprising how entangled these separate issues can become, in a discussion where one party may be worrying about the former and the other about the latter.” I fear that something of this nature is what is happening between Ms Stevens and myself. We must be very clear about which discussion we are having, using which professional guidelines and structures. Otherwise there is just muddle and misunderstanding.

Paradoxically, one aspect of secrecy in the NHS is highlighted in my review of the “supervision book” as a cause of risk.⁴ As the NHS professional I am arguing for proper consultation between members of the team. This extends to a supervisor of course. In the private setting this is adapted properly so that the supervisor does not know who the patient is. There are firm, established professional guidelines both for the NHS and private practice. Ms Stevens is arguing for the rights of patients. Again, there are firm and established guidelines. But these are different guidelines and the reality in a dispute is necessarily a compromise reached through negotiation.

There is currently much media attention to the impossible decisions which have to be made around the conjoined twins and the paradoxically conflicting moral and ethical opinions involved. “The extraordinary thing about these life and death medical ethics is that they knit a tangled web of contradictory principles.”⁵ Toynbee highlights that having objected so strongly to the planned death of a vegetative patient, the pro-life group find themselves supporting the death of twins in objecting to surgery to save one of them.

Perhaps we professionals and patients alike should take this opportunity to give each other a little more width before protesting unhelpfully.