Paramedicine: Ethical, Legal and Professional Obligation to Ensure Confidentiality
1.0 Introduction
As a relatively young profession, paramedicine has borrowed from existing medical practice in the development of its guiding ethical principles. One such principle is confidentiality. The origins of medical confidentiality go back some 2,500 years to the Hippocratic Oath. Modern confidentiality is thought to have evolved from the work of an English physician, who in the late 1790s wrote “and the familiar and confidential intercourse, to which the faculty are admitted in their professional visits, should be used with discretion, and with the most scrupulous regard to fidelity and honor”. This statement points to the moral duty for medical practitioners, and by extension paramedical professionals, to maintain the privacy of information provided by their patients in confidence, on the basis that this safeguards patient wellbeing.
This principle is reflected in both the Professional Capabilities for Registered Paramedics (PCRP) and the Paramedic Professional Competency Standards (PPCS), which govern the expectations of professional paramedical practice within Australia. For example, as part of demonstrating professional and ethical conduct, paramedics are held responsible for “ensuring that patient/service user confidentiality and privacy is maintained”. In order to achieve this, paramedics must first have a clear understanding of what confidentiality entails.
This essay will explore the concept of confidentiality as it applies to paramedical professionals, including their ethical, legal, and professional obligations. It will start with explaining the theoretical basis of confidentiality, before providing a critical analysis of the topic, discussing of its practical application in the prehospital care setting, and summarising with concluding remarks.
2.0 Theoretical Explanation
Confidentiality, by the Oxford English dictionary definition, is “the state of keeping or being kept secret or private”. However, maintaining confidentiality in the provision of unscheduled and often emergency prehospital care is far more complex than paramedics simply keeping a secret. One source describes confidentiality and privacy as having three components: i) physical privacy, relating to exposure or interference with the patient’s body; ii) decisional privacy, or the right to make decisions autonomously; and iii) informational privacy, or the protection of personal information from disclosure to outsiders. While all three components are important, it is informational privacy that is most associated with confidentiality.
Paramedical professionals have an ethical, legal, and professional obligation to protect the confidentiality of health information, gained in the provision of care, from misuse or disclosure to unauthorized persons without the patient’s permission. Protected information includes (but is not limited to) demographic data which may identify an individual, physical and mental health history, and treatment provided. This information must be protected from disclosure either deliberately or inadvertently by verbal, written, electronic, or any other means.
Confidentiality is underpinned by the bioethical principle of autonomy. Autonomy refers to the idea that patients should be respected as self-determining individuals, and able to freely make informed decisions about their care without interference from others. An important aspect of respecting patients as individuals is respecting their right to decide what personal information is disclosed, and who it is disclosed to.
3.0 Discussion and Critical Analysis
In order for prehospital healthcare to be effectively delivered, a trusting relationship must exist between patient and clinician. The patient must feel safe enough to divulge the truthful information required for the clinician to identify relevant medical conditions and commence treatment. It is a reasonable expectation of patients that in return for their openness, sensitive personal, medical, and social information will be kept private, and will only be shared with those immediately involved in the provision of care. This expectation is addressed in the PCRP, in which Domain 2 Capability 1 specifies that paramedics communicate with patients, families, and carers in a manner respectful of patient confidentiality, privacy, and dignity.
As paramedics are only with their patients for a short timeframe, it stands to reason they may leverage off the paramedical profession’s trusted reputation for confidentiality to rapidly develop the relationship described above. The PCRP and PPCS contribute to this trusted reputation by providing strong guidance on expectations, including maintenance of confidentiality. PPCS Competency 3.1 requires that professional paramedics to “practice within the legal and ethical boundaries of their profession” and in doing so “maintain the privacy and confidentiality of information”. PCRP Domain 1 Capability 1 similarly requires paramedics to demonstrate an understanding of the legal responsibilities of the profession, specifically those relating to maintaining confidentiality.
The medico-legal framework governing confidentiality consists of both common and statutory law. In simple terms, paramedics owe a common law duty of confidentiality to those they treat. If confidentiality is breached disciplinary actions may result, including sanctions by the paramedic’s employer or registering body, or civil action by the person wronged. A complex array of federal and state-based legislation also dictates confidentiality requirements. The Privacy Act 1988 (Cth) s.16B, the Health (Miscellaneous Provisions) Act 1911 (WA), and the Freedom of Information Act 1992 (WA) are just some of the more pertinent laws governing the collection and distribution of health information within Western Australia.
Despite (or perhaps because of) the principles, rules, and regulations discussed above, ethical dilemmas can present challenges surrounding confidentiality due to the uncertain and unpredictable nature of emergency situations. The dilemma arises where there is a conflict between two or more competing needs. For example, where disclosure of sensitive information is required to deliver care to a critically unwell patient or to protect public health from a potential disease threat. In situations such as these, paramedics may employ a number of ethical decision-making strategies, including basing decisions on scene atmosphere, on assessment of the patient’s condition, and on predicted outcomes of the decision.
4.0 Application to Practice
At the most basic level, the practical application of confidentiality to the prehospital care setting relies upon paramedics to self-sensor, and ensure patient particulars are only disclosed to those involved in their care, and not to other colleagues, friends, family, or on social media. Koskimies et al. identified that while most paramedics surveyed respected and complied with confidentiality, this was situational, and may be negatively impacted by indifferent attitude or low knowledge of individual paramedics.
The physical setting in which prehospital care is provided presents unique challenges to maintaining confidentiality. When treating in a public setting, relatives, curious bystanders, and even other patients may view or overhear patient interactions, compromising confidentiality. To combat this, it is suggested that the patient be moved to a private location such as the ambulance as soon as it is clinically appropriate to do so and that bystanders may be requested to respect the patient’s privacy. Making phone calls in public or handing over care in crowded emergency departments presents similar challenges, as information may be inadvertently overheard by people waiting nearby. Simple measures such as being aware who is listening, lowering the volume of voice, and seeking a more private space may assist in maintaining confidentiality.
Maintaining the confidentiality of patient care records requires particular attention. With developments in information technology, there is an enhanced ability to share medical data electronically, however, this comes with an increased risk of an inadvertent breach in confidentiality. PCRP Domain 4 Capability 4 specifies that patient records must be appropriately maintained, complying with confidentiality and privacy requirements surrounding the ownership, storage, retention, and destruction of patient care documentation. In practice, this involves secure storage of documentation, whether that be in hardcopy or electronically, that prevents viewing of records by people not immediately involved in the patient’s care.
5.0 Conclusion
In summary, clinicians working in the prehospital setting have an ethical, legal, and professional obligation to ensure patient confidentiality. This duty extends to protecting patient identifiable information including demographic details, medical history, and treatments provided from being disclosed either deliberately or inadvertently without patient permission. In practical terms, the application of confidentiality to the prehospital care setting depends on factors including the behaviors of paramedical professionals, the physical constraints of the care environment, and the secure handling of patient records. Failure to comply with the requirements for confidentiality could result in not only the destruction of the integral patient-clinician trust, but also professional sanctions or legal consequences.
6.0 References
- Brenner, J. M., Aswegan, A. L., Vearrier, L. E., Basford, J. B., & Iserson, K. V. (2018). The ethics of real-time EMS direction: Suggested curricular content. Prehospital and Disaster Medicine, 33(2), 201-212. https://doi.org/10.1017/S1049023X18000110
- CAA, C. o. A. A. (2013). Paramedic professional competency standards. Retrieved from https://www.caa.net.au/images/documents/resources_for_universities/Paramedic_Professional_Competency_Standards_V2.2_February_2013_PEPAS.pdf.
- Curtis, K., & Ramsden, C. (2016). Emergency and trauma care: For nurses and paramedics (2e ed.). Chatswood, NSW: Elsevier Australia.
- Freedom of Information Act 1992 (WA). Retrieved from https://www.legislation.wa.gov.au/legislation/statutes.nsf/main_mrtitle_353_homepage.html
- Koskimies, E. M., Koskenniemi, J., & Leino-Kilpi, H. (2019). Patient's informational privacy in prehospital emergency care: Paramedics' perspective. Nursing Ethics, 969733019834977-969733019834977. https://doi.org/10.1177/0969733019834977
- Latchman, K. (2013). Professional and legal issues. In V. Nixon (Ed.), Professional practice in paramedic, emergency and urgent care (pp. 132-153). Retrieved from https://ebookcentral.proquest.com/lib/curtin/reader.action?docID=1174347.
- Lexico. (2019). Lexico: Powered by Oxford. Retrieved from https://www.lexico.com/en?search_filter=dictionary.
- PBA. (2018). Professional capabilities for registered paramedics. Retrieved from https://www.paramedicineboard.gov.au/professional-standards/professional-capabilities-for-registered-paramedics.aspx.
- Torabi, M., Borhani, F., Abbaszadeh, A., & Atashzadeh-Shoorideh, F. (2019). Ethical decision-making based on field assessment: The experiences of prehospital personnel. Nursing Ethics, 26(4), 1075-1086. https://doi.org/10.1177/0969733017736925
- Townsend, R., & Luck, M. (2013). Applied paramedic law and ethics Australia and New Zealand. Chatswood, N.S.W.: Elsevier Australia. Retrieved from https://ebookcentral.proquest.com/lib/curtin/reader.action?docID=1724010.
- Woolcock, M. (2017). Does precedence trump in the origins of confidentiality? Journal of Paramedic Practice, 9(12), 538-540. https://doi.org/10.12968/jpar.2017.9.12.538
