Discuss the management of the case, from an ethical perspective, considering your own views and how you would deal with another similar case.

Below is a model answer of the assignment and template Setting of medical rotation is the middle east

you will need to identify a case which involves one or more ethical dilemmas.
This case must be written up on the template provided and uploaded onto Moodle.
This must be an ethical dilemma that you encountered.
You may read the model answer below as a guide to how you should complete your ethical case report. Keep your answers brief. The maximum total word count is 1,000 words.
Q1. Give a brief outline of the case from a clinical perspective.
I was sitting in with my GP Tutor when a mother, Mrs B, attended regarding her concerns about her 19 year old daughter, Miss A. Mrs B, wanted my Tutor to give her medical information about her daughter as she was worried.
The doctor was very sympathetic to Mrs B but explained that her daughter’s medical information was confidential. Mrs B was quite forceful with the doctor, saying that she was A’s mother and she had a right to know. The doctor remained sympathetic, repeated that she had a duty of confidentiality, stated that she understood why Mrs B wanted to know and that she obviously cared for her daughter greatly. She invited Mrs B to share any concerns that she had.
Unfortunately this did not help. Mrs B became quite angry towards the doctor, stating she was going to make a formal complaint, and left, slamming the door.
Q2. Identify all the ethical and legal (if relevant) issues(s) of this case.
I will use a Four Principle approach[i]:
1. Beneficence
A doctor must act in what he/she sees as the patient’s best interest. This may differ from a parent’s opinion. Mrs B’s motives may be to help her daughter, however firstly this point is extremely uncertain therefore unreliable as a guide to action. Secondly even if it were true, it is for A to define what will benefit her, not her mother. Thus beneficence will not support breaking confidentiality.
2. Nonmaleficence
It is likely that A would be distressed if her confidentiality is broken. There is also the possibility of further harm, such as Mrs B interfering with A’s activities and obstructing her goals. Also A may feel that the relationship of trust with her doctor had been broken, making it less likely that she will confide in her doctor in the future, increasing the likelihood of sub optimal medical care.
3. Respect for autonomy
This is the deciding factor in this consultation[ii]. Autonomy literally means “self rule” and part of this is having control over one’s own affairs, including control over who should or should not have access to your personal information. Also as we are all part of relationship networks control over our personal information may have a practical importance in ensuring that we can control outside influences over ourselves to prevent coercion which negates autonomy.
“Respect for autonomy” recognises that autonomy may not always be present, for example if someone lacks capacity[iii]. One aspect of this is the legal age of consent. An adult however must be assumed to possess capacity unless there is a good reason to think otherwise, in which case an assessment of capacity may be needed. As A is over the legal age of consent and there is no suggestion of lack of capacity then her autonomy must be respected, thus her medical confidentiality must be preserved.
The law also enforces the medical duty of confidentiality for adults, other than in certain unusual exceptions such as the possibility of serious harm to third parties or certain statutory duties[iv].
4. Justice
There are no issues of distributive justice in this case. However to break this patient A’s confidentiality would be unjust to her. Also Mrs B has no legal right to her daughter’s information, so no injustice is being done to Mrs B.
Q3. Discuss the management of the case, from an ethical perspective, considering your own views and how you would deal with another similar case.
First impression of the case.
At first I thought the issue was straightforward, but when Mrs B insisted, as a caring mother, I felt unsure. I was really surprised when Mrs B became angry. I realized she might also have become angry with her daughter if she didn’t like something about her daughter’s consultations. Then I realized how important it was to stick to the rules[v],[vi],[vii].*
How the GP dealt with the case
The GP was really skillful in handling Mrs B sympathetically. My first reaction would have been just to say “no” to Mrs B. The GP explained that she knew it was difficult for a mother not to know her daughter’s business, and that she could see how much the mother cared, but that she had a duty of confidentiality to A as A was an adult. However even with this approach the consultation went badly.
Strengths and weaknesses in how it was handled
I’m sure the GP was right to both express sympathy to Mrs B but also stick firmly to the rules of confidentiality. The GP asked Mrs B what her worries were and she was very sympathetic towards Mrs B, which I thought was really good.
I don’t think there was really a weakness because the doctor was faced with a clear rule which she could not break. Perhaps “duty of confidentiality” might have sounded a bit bureaucratic to the patient though.
Alternative management route
I wondered about two possibilities:
· I wondered if Mrs B thought that breaking a “medical rule” might not really be serious. Perhaps the doctor could have explained that it is an IMC/GMC/NHRA** requirement, and that she would also be breaking the law if she broke confidentiality.
· I wondered if offering Mrs B to come back with her daughter, if the daughter wanted it, for a three way discussion might help.
Would you feel better equipped to deal with this case if it occurred again?
· It is really important to have the basic ethical principles and rules very clear in one’s mind, as a doctor never knows what is about to crop up, and has to react to patients rapidly.
· I was really surprised that a patient could become angry even when the doctor was doing the right thing. I realized that doctors need really good communication skills, especially with difficult patients.
· I realized I was not clear about the law on confidentiality (as opposed to the ethical principle), so I looked it up.
· I realized that my doctor was upset after this consultation. I was embarrassed at the time and I didn’t know how to handle the situation. We went and had a cup of tea, and she told me it was important that we had five minutes to deal with our emotions before we went on to see the next patient[viii].
· I learned that doctors are at risk of complaints even when they do what is right.

[i] Beauchamp T and Childress J. Principles of Biomedical Ethics. Oxford: Oxford University Press, 7th Edn 2013.
[ii] Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994; 309(6948): 184–188.
[iii] Beauchamp T and Childress J. Principles of Biomedical Ethics. Oxford: Oxford University Press, 7th Edn 2013, p114.
[iv] Hope T, Savulescu J and Hendrick J. Medical Ethics and Law. Edinburgh: Churchill Livingstone, 2nd Edn 2008, p 101.
[v] GMC. Confidentiality Guidance: Principles, 2009. http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality_6_11_principles.asp Accessed 11/10/15.
[vi] IMC. Guide to Professional Conduct and Ethics for Registered Medical Practitioners. 2009, p26.
[vii]NHRA guidelines for maintaining medical confidentiality in Bahrain:
http://www.nhra.bh/files/files/Healthcare%20Professionals/Dr%20%20Code%20of%20Ethics.pdf Ch 2. Accessed 11/10/15
[viii] Neighbour R. The Inner Consultation – how to develop an effective and intuitive consulting style. Lancaster, Kluwer Academic Press, 1987, p211.

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