ConfidentialitySlide 2Why Is Confidentiality Important?Confidentiality and AutonomySlide 5Slide 6Slide 7When to Override Confidentiality?Overriding ConfidentialityReporting Law: A Special CaseApproaches to Ethical ReasoningSlide 12PrinciplesCases (Casuistry)The “Truth” Line of CasesDifficult CasesReasoning About CasesSlide 18Reflective EquilibriumConfidentialityModes of Ethical ReasoningConfidentialityOne of few modern health care ethics precepts included in Hippocratic OathEveryone says it is seriousNo one says it is absoluteWhy Is Confidentiality Important?What if no bad consequences follow from revealing private information?Most people would feel wronged even if no bad consequencesSuggests moral reasoning is more Kantian than utilitarian (respect for persons)Confidentiality and AutonomyHow is violation of confidentiality a threat to personal autonomy?Control over intimate relationshipsMeMostintimateMost distantMeMostintimateMost distantChoosefreely todisclosepersonalinformationMeMostintimateMost distantChooseto withholdpersonalinformationWhen to Override Confidentiality?High risk of serious harm to identifiable personNo alternative way to avoid harmOne takes steps available to minimize harm to patient from disclosureOverriding ConfidentialityTo prevent harm to a third party (see previous justifications)To prevent harm to the patient (same criteria as justifying paternalism)Reporting Law: A Special CaseLaw is publicly knownWe have obligations to know what the law isTherefore can argue that patient has implicitly given consent if now seeking medical care under those circumstancesHow valid a justification?Approaches to Ethical ReasoningPrinciplesCasesEither-or or both-and?Abstract principlesConcrete specific judgments PRINCIPLES CASESPrinciplesEthical wisdom lies in a small number of concise, abstract principlesFrom principles can deduce what to do in a given caseCase “anecdotes” are merely illustrative of the correct application of principlesCases (Casuistry)Ethical wisdom consists of detailed, nuanced, concrete judgments about specific casesOften uses maxims or rules but these are general organizing concepts, not infallible sources of ethical insightOften a rule or maxim creates a line of casesThe “Truth” Line of CasesMaxim: Don’t lieParadigm case: George W. and the cherry tree“Line of cases”: Each new case differs just a little more from the paradigm case; as one gets farther away a wider variety of other ethical considerations compete with the maximDifficult CasesKant: Do you tell the truth to the homicidal lunatic who asks which way your friend went?At intersection of two lines of cases-- “Don’t lie” and “Protect lives” maximsReasoning About CasesDifferenc es : how two cases which at first glance seem identical actually have features requiring different ethical analyses or actionsAnalogy: how two cases which at first seem quite different actually have common features which may point to an ethical resolutionAbstract principlesConcrete specific judgments REFLECTIVEEQUILIBRIUMReflective EquilibriumLook for best overall “fit”Reason both from cases to principles and from principles to casesSometimes a specific case judgment will seem better “grounded,” other times a principle willBe willing to revise ethical judgments based on new ideas and