A female patient presents to the emergency department with an arm fracture status post a fall. She privately discloses to the physician assistant (PA) that the arm fracture was due to intimate partner violence and asks the PA not to document the true nature of the fracture as well as not to inform the attending physician, as both the patient and the patient’s husband have worked in the hospital. The patient also refuses any examination or treatment related to intimate partner violence (Jenkin, 2006).
The PA faces the conflict of whether or not to honor the patient’s request for nondisclosure through documentation and communication with the attending physician (Kirk, Confidentiality Discussion Exercise Handout, 2019).
In regard to this clinical case, the ethical principles of autonomy and nonmaleficence can be observed and appreciated. Autonomy is a patient’s right to determine his or her own course of action. This translates through free action, which involves the patient’s voluntary choice to make a decision, as well as effective deliberation, which involves the patient’s ability to carefully evaluate the harms and benefits of his or her decision and proceed with his or her choice having weighed the consequences (Yeo and Moorhouse, Autonomy, 2010). Nonmaleficence is the ethical principle of minimizing, removing or preventing harm, which may also produce benefit. This also involves preventing the potential risk for further harm, both physical and emotional (Yeo, et al., Beneficence, 2010).
Therefore, the patient’s request for nondisclosure should be respected by the PA, an action consistent with both ethical principles of autonomy and nonmaleficence.
By not disclosing the patient’s true cause of injury, the PA respects the patient’s autonomy. The patient is alert, oriented and has full decision-making capacity through which she is able to effectively deliberate the harms and benefits of her choice to keep her partner’s violence private information. She accounts for the possible ramifications of nondisclosure as they relate to both her and her children’s well-being and safety. The patient measures the risks of her decision in that she expresses that her children are not in immediate harm as they are safe in her mother’s care. She also communicates her hesitancy for disclosure due to her husband’s reputation in the medical field, and as such, maintains her decision to not jeopardize his professional future and career. The patient, clear with her understanding of the options of disclosure and nondisclosure and their subsequent consequences, is able, with the right, to make her own informed decision.
In relation to free action, the patient has the liberty to consent to or refuse proposed clinical care despite the severity of her current family situation, as she is not mandated to disclose the truth of it. The patient has the right to refuse disclosure despite the benefits that may be provided with the converse action. Despite what the PA feels is most appropriate, she must maintain patient confidentiality and not violate the patient’s trust in her as her care provider as well as in the healthcare system. Nondisclosure respects the patient’s confidentiality in that it protects her honest communication and establishes further loyalty in her relationship with the PA (Kirk, Confidentiality, 2015). Thus, by respecting the patient’s autonomy and staying true to confidentiality, the PA maintains the patient’s nondisclosure decision.
By maintaining allegiance to the patient and her decision, the PA upholds the ethical principle of nonmaleficence. Honoring the patient’s decision for nondisclosure prevents harm in that the PA does not act in a way that will deter the patient from seeking future treatment for additional partner violence related injuries, as her compliance in confidentiality will not compromise the PA and the healthcare system as a safe place for the patient. The PA exhibits nonmaleficence as honoring the patient’s decision may reduce the patient’s potential risk of additional perhaps more severe harm should her husband find out about the disclosure. Disclosing her intimate partner violence against the patient’s will may also force the patient into a situation she is not ready for emotionally, socially or financially and leave her ill-prepared for possible consequences associated with her husband and her children. Moreover, if the PA discloses the information, the patient may be subject to multiple psychosocial harms, such as unresolved resentment towards the PA, and perhaps the attending, causing feelings of isolation and distrust. In addition, if the PA discloses this information in documentation and to the attending without notifying the patient, it may produce more harm to the patient as the patient will eventually discover that she was deceived. By reinforcing trust, the PA upholds nonmaleficence and maximizes the patient’s clinical outcomes at this visit by treating her current injury and preserving her confidence in the healthcare system.
As intimate partner violence is sensitive in nature, it is possible that other medical professionals would suggest counterarguments to this nondisclosure, such that nonmaleficence could actually be violated in this case. Without disclosure of intimate partner violence, the patient and her children could be at risk for continuing as well as worsening abuse. This is especially true for this patient as intimate partner violence tends to escalate, and by the next visit, the patient may have more severe or increased harm or injury. Others could also argue that the PA can be held accountable for negligence if the patient suffers life-threatening abuse, potentially leaving the patient’s children motherless, in which case, the patient’s husband’s role as the abuser would also eventually be revealed, leaving the argument of the patient wanting to keep her husband’s identity untarnished unsubstantiated.
By respecting the patient’s nondisclosure wishes, the PA maintains the patient’s trust and truthfulness in the clinician. If these principles are maintained during this emergency department visit, the patient may change her mind about nondisclosure in the future when she feels she is ready to disclose the violence in a formal documented manner. However, if the counterargument is applied, the patient may not come back to the emergency department with other injuries sustained through violence because she feels she cannot trust the clinician or the healthcare system to act accordingly or in the best way of disclosure as a result of the previous violation of confidence. The act of goodwill on the PA’s part does not outweigh the importance of the patient’s decision of when and in what conditions to disclose the intimate partner violence information. Ultimately, the counterargument established goes against the patient’s goals of her visit as well as her autonomy and can lead to preventable harm.
At this emergency department visit, the patient requests that the information regarding the true reason for her arm fracture due to intimate partner violence not be disclosed via documentation and to the attending physician. Honoring and respecting the patient’s request for nondisclosure supports and respects the patient’s autonomy in that it recognizes that she has the choice to make an informed decision about her care and private information, as she shows that she thoroughly understands the harms and benefits of that conscious decision. In regards to nonmaleficence, the patient maintains trust in the PA in that she will have her present injury treated and feel that she can confidently trust her in the future without fear that she will be misled on what will be disclosed, both of which maximize the beneficial outcomes for the patient and avoids preventable harm.
References
Jenkin, A, Millward, J. (2006). A moral dilemma in the emergency room: Confidentiality and domestic violence . Accident and Emergency Nursing, 14(1), 38-42.
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.
Kirk, TW. 2019. Confidentiality Discussion Exercise Handout.
Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
Yeo, Michael et al. (2010). Beneficence . In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.
