College of Medicine University of Ibadan, Nigeria (Spring 2010)
In Africa, as elsewhere in the world, healthcare professionals are bound by ethical codes not to disclose information given to them by their patients. Yet despite the best of efforts, neither confidentiality nor privacy can always be easily guaranteed, as exemplified by a look at problems encountered at a public hospital in Ibadan, Nigeria.
In the outpatient clinics, privacy of patients is supposed to be guaranteed by interviewing them behind closed doors in a designated consulting room. However, in order to avoid suggestions of impropriety or immorality on the part of a male provider, a female patient is statutorily interviewed with a hospital chaperone or a registered nurse in attendance. By having a third party at the interview, the patient’s privacy is already compromised. In some cases, the patient may ask to see the doctor alone, in which case the chaperone is excused, but the door to the consulting room is necessarily left open. Discussions then take place in low tones or whispers so that others cannot overhear the discussion. This is an example of confidentiality without absolute privacy.
In most teaching hospitals, the records of admitted patients are exposed to medical students and student nurses, persons who have not been admitted into any learned society and thus are not strictly bound by an oath, Hippocratic or otherwise. During their training, these individuals have unfettered access to patient information, either during ward rounds or by reviewing the records. Although it is understood that they must keep this information confidential, this is not easily enforceable.
Years ago, doctors did everything: interview, examine, investigate, and treat patients. Now medicine has become specialized; there are hematologists, chemical pathologists, morbid pathologists, microbiologists, and radiologists, who may all participate in diagnosis and treatment of a particular patient. To obtain their services, the primary physician has to fill out a form stating the patient’s name, age, sex, and diagnosis. Even if the patient has HIV-AIDS, the physician is obliged to include this information on this form, in part raise his colleagues awareness regarding exposure to blood and other body-fluids. It may be argued that members of the medical profession are bound by the Hippocratic Oath, but these forms and their results are also recorded and released by departmental clerks who are not bound by oath.
When high-ranking individuals, such as ministers, senators or ambassadors, are infected with HIV, they may receive anti-retroviral drugs in private at designated HIV-clinics. However, if these individuals require surgery, they have to be referred to a surgeon, thus disclosing their HIV-status. While many of them request that this information not be divulged to other members of the operating team, it is the duty of the surgeon to inform other operating theatre workers (anesthetists, nurses, porters and cleaners) to ensure that proper precautions are taken. After all, disposal by incineration of soiled or contaminated theatre linen is performed by the cleaners who are not sworn to any oath of secrecy.
Recently, I was driving past the out-patient extension of a clinic that everybody knows is designated for HIV-positive patients, and I witnessed the early patients queuing up before the doors opened. Had I recognized any one of them, it would not have been their fault or mine. Yet privacy and confidentiality would have been compromised by the hospital’s failure to provide a secluded or partitioned area where patients could wait without being seen in public.
Problems with confidentiality also arise with other issues such as erectile impotence, sexually transmitted diseases, and accidental blood group findings that may lead to paternity disputes. In such cases, biological samples may have to be sent to a laboratory, where clerks register completed request forms and labelled containers of biological samples. The crux of the matter in this circumstance is that leakage of confidential information is often not from the doctor, but from indispensable hospital support staff present at the clinic or lab at that point in time. For this reason, presidents of certain West African countries sometimes prefer to receive trivial medical treatment abroad. It is a dominant belief in their culture that illness portends a bad destiny and that all leaders should be immune from ailments. Consequently, many leaders who are unhealthy will distance themselves from their people to ensure confidentiality and privacy in order to perpetuate the myth of their invincibility.
When a society is confronted with the death of a leader or other authority figure, their confidentiality rights are further compromised. It has been said that death ends the right to privacy but not to confidentiality. Therefore, the medical records of a deceased president, for example, should not be released to the public at the discretion of a healthcare provider or family member. However, when the legendary musician Fela Anikulapo Kuti died, his elder brother, a professor of paediatrics and head of the Kuti family, convened a press conference that revealed that Fela had died of AIDS. A revelation such as this clearly constitutes the breach of a person’s right to confidentiality, regardless of whether the person is alive or dead.
What can be done then to ensure patients’ privacy and confidentiality in Nigerian hospitals or other public hospitals in the world? One option would be to have consulting rooms where patients may see their physicians privately. Yet the mere fact that places are set aside for privacy could engender rumors about those who visit them, which may end up being even more damaging than the actual facts. Another approach that has occasionally worked well is to use pseudonyms on the pathology request form for individuals who want their medical records to be kept confidential. In this instance, only the patient’s private physician would know their real name. While doctors and nurses are under obligation to maintain professional secrecy, I believe this obligation should also be impressed on cleaners, ward maids, and maintenance men. I suggest that the entire medical staff should promise to uphold absolute secrecy, and that any leakage of information should result in prosecution. Perhaps then, the privacy and confidentiality rights of patients can be further protected and less controversial in public hospitals throughout the world.
DAVID IRABOR, MD is a general surgeon by training, a Fellow of the West African College of Surgeons, Consultant Surgeon to the University College Hospital at Ibadan, and a Senior Lecturer in Surgery for the College of Medicine University of Ibadan, Nigeria. Apart from his love of gastrointestinal surgery, he has a keen interest in biomedical ethics. He was a 2005 Fellow of the South African Research Ethics Training Initiative (SARETI) and apart from over 32 publications in the field of general surgery, he has 3 publications in the field of ethics. Dr. Irabor is happily married with children. He can also be reached at dirabor[at]comui.edu[dot]ng.