To Disclose or not to Disclose?
“Jenkins (2006) presents a case in which a patient presents with an arm fracture due to a fall, but then privately discloses to the nurse that the injury is due to intimate partner violence. The patient asks the nurse (Jenkins) to (a) not document the true cause of the injury and (b) not inform the attending physician of the violence incident, thereby also refusing examination/treatment of any other injuries sustained during the incident.” (Kirk, 2015).
The ethics question is “should the PA honor the patient’s request for nondisclosure?”
Two ethical principles most relevant in addressing this ethical question are beneficence/nonmaleficence and autonomy.
Based on these principles, we recommend that the PA should honor the patient’s request of non-disclosure, and not document in the chart nor tell the attending physician about the violence incident.
The principle of autonomy can be understood in four ways. Autonomy as free action is liberty, the patient’s ability to do as she wishes, or not be forced to do what she does not want to do, without someone or something else making the decision for her (Yeo et al, 2010.) If the practitioner discloses the patient’s domestic situation without her consent, she is taking away this aspect of the patient’s autonomy. In honoring the patient’s wishes of nondisclosure, the PA is allowing the patient to have a say in her own care, thereby following this aspect of autonomy.
The second explanation of autonomy is autonomy as effective deliberation, meaning that the patient goes through a rational thought process in order to come to a well thought out conclusion. This is based on the patient having all the information about the situation and choosing the outcome that is most in line with her goals (Yeo et al, 2010). In this case, there is no evidence or reason to believe that the patient is impaired in any way and cannot think rationally. Therefore, we assume this patient has full decision making capacity because she is oriented to person, place, and time. We also assume that she understands the consequences that may result from both disclosure and non-disclosure which can affect both her and her family members. In addition, this patient knows the most about her own partner, living situation, community, culture, and psychological state, and therefore we assume that her deliberation is effective because she is making her decision with all of these factors in mind.
Beneficence and nonmaleficence can also serve as ethical principles to justify the decision to not disclose the information. Beneficence can be defined as promoting the good or welfare of others. This can be accomplished by acting in line with the patient’s goals of care. The result of the chosen action should have the most benefit for the patient physically, mentally and socially. The harms and benefits of each option need to be weighed, and the option that allows the most good with the least possible harm is the beneficent choice (Yeo et al., 2010.) In this regard, by respecting the patient’s wishes to not disclose, we are building a relationship of trust with the patient which can be beneficial to her both now and in the future. During this visit, she will feel more comfortable opening up to the PA who is treating her and perhaps allow her to do further testing or examine other areas of her body that may have been affected by abuse. In general, respecting a patient’s wishes and treating them as partners in medical decisions, instead of a “paternalistic” approach, will help the patient feel more comfortable coming to medical professionals for help because that confirms that they are trustworthy. This support from medical professionals may help her trust them enough until she gets to a point where she feels comfortable and ready to disclose the violence incident and get the proper help.
Non-maleficence can be defined as the outcome that inflicts “no harm,” or results in the least amount of harm to the patient (Yeo et al., 2010.) In this case, we are not sure why the patient is asking to not disclose, but since we assume effective deliberation, it is reasonable to assume that she believes that her choice to not disclose will cause her less harm than if the information were to be disclosed. Disclosing against the patient’s wishes might have negative psychosocial ramifications for her, which would be harmful to her. For example, if her community finds out that she is having issues at home, or if this results in a separation or divorce, it may cause her to be looked down upon or be shunned. Furthermore, disclosure might lead to more violence from her husband in retaliation, increasing the harm rather than minimizing it. For example, her husband might get angry at her if she discloses this negative information about him (perhaps because it ruins his image or because he will need to face certain consequences), and he can become increasingly violent towards her as a result. He may have also threatened her in the past that if she discloses he will harm her even further. Her past experiences with disclosure or non-disclosure of abuse will be informing her decision, so if she is requesting to not disclose, we can assume that she believes that non-disclosing will be the best option to minimize future harm to herself.
One strong counterargument is that by not disclosing, the medical professional is not following the principle of beneficence, since by leaving the patient to continue living as she is currently with her potentially abusive husband, she is left in a dangerous situation where she may be harmed further. Moreover, one can argue that the patient may not have full decision making capacity because her immense fear of her partner is clouding her judgement, and if she was really free to decide what to do she may wish to disclose.
Despite the counterarguments of the patient possibly not having full decision making capacity, or that the patient will have increased harm due to retaliation, the decision to disclose is still justified because disclosing will respect the patient’s autonomy and will be towards her goals of care, thus in line with beneficence. The likelihood of harm to the patient associated with disclosing seem greater than the likelihood of benefit or reduced harm associated with not disclosing. Furthermore, the counterarguments each have flaws. The argument that she does not have full decision making capacity may not be substantial because fear may not be clouding her judgement, but rather may be better informing her decision, so she would be making a logical choice, and taking into consideration the results that she fears may occur. Also, we do not know for sure that disclosing will reduce physical harm; it could have the opposite effect. Psychosocially she needs to be mentally ready to take action against her partner, and if she does not disclose willingly she will probably not follow up effectively.
Therefore, based on the principles of autonomy and beneficence/ nonmaleficence, we recommend that the PA should honor the patient’s request of nondisclosure.
Yeo, M., Moorhouse, A., Kahn, P., & Rodney, P. (Eds.). (2010). Concepts and cases in nursing ethics. Broadview Press.
Kirk, TW. (2015). Confidentiality . In N Cherny, M Fallon, S Kaasa, R Portenoy, & D Currow (eds.). Oxford Textbook of Palliative Medicine. (5th ed.) New York/London: Oxford University Press, pp. 279-284.