Confidentiality case study: elder abuse
Should a doctor disclose evidence of abuse without the patient’s consent?
Part 1
Mrs Giggs is 87 years old. She is physically very frail, but mentally alert. Since she fell in her own home a year ago, she has been living with her daughter Julie, who is her main carer, and Julie’s husband Geoff. When she moved in, Mrs Giggs registered with the family’s GP, Dr Rix, who she has got to know fairly well.
On a home visit, Dr Rix notices some bruising on Mrs Giggs arms. When he asks about how these were caused, Mrs Giggs looks uncomfortable before telling him that what she’s about to say is shared in the strictest confidence.
Mrs Giggs says Julie’s husband, Geoff, has left, and that Julie has been drinking heavily. She says that Julie can get very upset, and that she probably said something to provoke her.
Dr Rix interrupts, asking if Mrs Giggs is saying that Julie hit her and whether it has happened before. Mrs Giggs is evasive at first, explaining her concerns for Julie and about how upset and angry she has been recently, before confirming that ‘it wasn’t the first time exactly’. She quickly reiterates that Dr Rix must not tell anyone: ‘I’m really worried about her; and she needs me … just as much as I need her. I’d hate her to get into any kind of trouble… it was probably my fault. I really am very happy here, you know, doctor. There’s no need to worry.’
Dr Rix is worried about Mrs Giggs’ welfare. What should he do?
- Should he try to persuade Mrs Giggs to tell anyone else (or allow him to)?
- If he can’t persuade her, should he contact social services to make a safeguarding referral, or the police to report a suspected crime? Or should he respect his patient’s decision? She’s a competent adult.
There is a clear public good in a confidential medical service. Confidentiality is central to trust between doctors and patients. The fact that people are encouraged to seek advice and treatment, and to be open and honest with their doctors, benefits them and society as a whole. However, there can also be a public interest in disclosing information, to protect individuals or society from risks of serious harm, such as serious crime (paragraphs 6 and 36).
Doctors should provide patients with information and support to make decisions in their own interests, for example, by facilitating contact with agencies that support victims of elder abuse. Patients should be encouraged to consent to disclosures considered necessary for their protection, and doctors should warn them of the risks of refusing to consent; but doctors should usually abide by a competent adult patient's refusal to consent, even if their decision leaves them, but nobody else, at risk of serious harm. Disclosure without consent may be justified if it is not practicable to seek a patient's consent (paragraphs 51 and 52).
In Scotland, doctors should be aware of the Adult Support and Protection (Scotland) Act 2007 (ASP(S)A), which requires health boards to report to local authorities if they know or believe that a vulnerable, but not necessarily incapacitated, adult is at risk of harm and that action needs to be taken to protect them. The ASP(S)A code of practice (Scottish Government website) encourages those sharing or accessing confidential information to seek consent, if that is practicable; and reminds health professionals of their professional guidance on confidentiality (endnote 22).
Dr Rix encourages Mrs Giggs to let him contact social services about Julie’s behaviour, but she refuses. He concludes that Mrs Giggs is a competent adult, so he abides by her decision; but he does provide her with information about local charities working with elderly people and leaves her contact details for a support group, encouraging her to contact them.