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Edited by C Cordess. Jessica Kingsley Publications, 2001, £15.95 (pb), £47.50 (hb), pp 201. ISBN 1853028592
The respect for confidentiality and the rhetoric about openness of information are in conflict in contemporary society, and the tone of the conflict is increasingly inflamed. The senior professions are the battleground. Medical ethics is in turmoil from this social trend, as well as from the high profile technical developments in genetics, transplant surgery, and reproductive technology. But in addition mental health has always had its inherent problems over ethical practice since it has, to this day, inevitably retained some element of medical paternalism. This places practitioners in a position in which they have a responsibility for the care of their patient, but also a responsibility for the protection of society. The particular problems in mental health often have deep moral implications, that do not exist in general medicine.
Chris Cordess has produced a timely book in which he has written, with colleagues in the mental health, psychotherapy, forensic psychiatry and legal fields, 13 chapters on the current status of confidentiality, its protection and erosion. The chapters originated in a conference in 1998 with the same title as the book, and they are arranged largely according to the impact of the conflict on specific disciplines, rather than particular themes. But themes do recur through the text: the protection of children and third parties; the research use of case studies in journals and other publications; interdisciplinary and interagency exchange of information; the commercial interests of insurance companies and other organisations in the risk business; computer-stored records; disclosure in court and court reports, and so on.
The book is stuffed with the difficulties that are posed for practitioners and researchers by the social conflict over privacy and confidentiality. The professional consultation, not least in mental health, is aimed to be free of moral judgments; whilst public life is not. Traversing this boundary is difficult, and means that more complexities intrude into the interpersonal encounter, which is quite difficult enough already. Practitioners might resent these burdening intrusions; the suspicion always hovers over these pages that professionals might view the call for openness as having less beneficent and more prurient motives behind it. And this raises the concern that the book is special pleading by incommoded practitioners. Nevertheless, two chapters by lawyers are sympathetic to the problem, one advocating a “legally enforceable right of confidence for patients involved in legislation” (page 147). A thoughtful piece from Bill Fulford provides the introduction. He makes the point that medical ethics has gone too far in seeking ever more general principles to which doctors and therapists should conform in practice. Mostly these aim to restrict and exclude medical paternalism. However, he concludes bitterly that there is a risk of an ethicists’ paternalism, in which the claim that “the ethicist knows best” has taken over from “the doctor knows best”. The wishes of patients for confidentiality do in most instances coincide with the beliefs of doctors. The pressure to limit the doctor’s professional freedom of movement and to put his or her documents at the disposal of public scrutiny, neglects the clinical alliance and partnership between doctor and patient. Rules and regulations deriving from ethical principles need to be balanced. Because of the variety of different values, especially in mental health, between disciplines and cultures, principles need to be augmented by a process-focused consideration of individual cases.
Medical ethics has always stood for values being a part of medical practice as well as scientific facts. This is no less the case in mental health; in fact it is more so since one could argue that values are themselves the raw material on which the “science” of psychiatry must operate. Such a reflective complexity may justify mental health as being in a category of its own within professional and medical ethics. The claim to be a special case is never very distant from this text, and should be listened to by ethicists; whilst all clinicians will find the important issues readily accessible here.