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The doctor-patient relationship, confidentiality and consent in occupational medicine: Ethics and ethical guidance
[Thesis]. Manchester, UK: The University of Manchester; 2016.
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Abstract
This thesis seeks to examine the ethical basis for occupational medicine, as it is practised in the United Kingdom (UK). There is empirical evidence of occupational physicians being confused with regard to confidentiality and consent, and variations in their practice. It is argued that the ethical guidance from the General Medical Council and the Faculty of Occupational Medicine on these matters, contributes significantly to such confusion. The doctor-patient relationship, consent for disclosure of a medical report, and medical confidentiality, all in the context of occupational medicine practice, are explored. These issues are addressed in the core part of this thesis in the form of the three published papers. In the first paper, the doctor-patient relationship in occupational medical practice is reviewed, and it becomes apparent that in the UK, the occupational physician carries out different roles and functions, ranging from duties that mirror those of a therapeutic encounter, to those that require the occupational physician to be completely independent for the purposes of a particular type of assessment (for ill-health retirement). The former is compatible with the assumption of a fiduciary relationship between doctor and patient, whereas in the latter situation, it would be incongruous to expect the doctor to be independent and owe the patient a “duty of undivided loyalty” simultaneously. In the second paper, consent for disclosure of information, in particular a medical report, is distinguished from the “informed consent” for treatment or interventional research, and the phrase “permission to disclose” is proposed for the disclosure situations. Although this distinction may not have much significance in therapeutic practice, the output of virtually all occupational physician activities results in the writing of a report, so this difference between the two “consents” has greater relevance. The third paper reviews the ethical, and in particular, legal basis for medical confidentiality with reference to an independently commissioned report. In such a situation, UK courts have been consistent in stating that disclosure of such a report to the commissioning party does not breach confidentiality, and no further consent for such disclosure is required. This conflicts with ethical guidance to occupational physicians on this matter. Such conflict between the law and ethical guidance are a further, and important, source of ethical confusion for occupational physicians. Indeed, a common theme through the three papers is that ethical guidance to occupational physicians is in parts either incongruent, incoherent, or conceptually flawed. This may not be surprising, as current ethical guidance is predicated on a doctor-patient relationship that exists in the usual setting for most doctor-patient encounters, that is, the therapeutic setting. It seems unreasonable to expect that simply transposing such an ethical paradigm into a different setting, with dissimilar roles and obligations, could work in a seamless manner. The occupational physicians’ ethical confusion thus reflects the confusion in their ethical guidance.
Layman's Abstract
This thesis seeks to examine the ethical basis for occupational medicine, as it is practised in the United Kingdom (UK). There is empirical evidence of occupational physicians being confused with regard to confidentiality and consent, and variations in their practice. It is argued that the ethical guidance from the General Medical Council and the Faculty of Occupational Medicine on these matters, contributes significantly to such confusion. The doctor-patient relationship, consent for disclosure of a medical report, and medical confidentiality, all in the context of occupational medicine practice, are explored. These issues are addressed in the core part of this thesis in the form of the three published papers. In the first paper, the doctor-patient relationship in occupational medical practice is reviewed, and it becomes apparent that in the UK, the occupational physician carries out different roles and functions, ranging from duties that mirror those of a therapeutic encounter, to those that require the occupational physician to be completely independent for the purposes of a particular type of assessment (for ill-health retirement). The former is compatible with the assumption of a fiduciary relationship between doctor and patient, whereas in the latter situation, it would be incongruous to expect the doctor to be independent and owe the patient a “duty of undivided loyalty” simultaneously. In the second paper, consent for disclosure of information, in particular a medical report, is distinguished from the “informed consent” for treatment or interventional research, and the phrase “permission to disclose” is proposed for the disclosure situations. Although this distinction may not have much significance in therapeutic practice, the output of virtually all occupational physician activities results in the writing of a report, so this difference between the two “consents” has greater relevance. The third paper reviews the ethical, and in particular, legal basis for medical confidentiality with reference to an independently commissioned report. In such a situation, UK courts have been consistent in stating that disclosure of such a report to the commissioning party does not breach confidentiality, and no further consent for such disclosure is required. This conflicts with ethical guidance to occupational physicians on this matter. Such conflict between the law and ethical guidance are a further, and important, source of ethical confusion for occupational physicians. Indeed, a common theme through the three papers is that ethical guidance to occupational physicians is in parts either incongruent, incoherent, or conceptually flawed. This may not be surprising, as current ethical guidance is predicated on a doctor-patient relationship that exists in the usual setting for most doctor-patient encounters, that is, the therapeutic setting. It seems unreasonable to expect that simply transposing such an ethical paradigm into a different setting, with dissimilar roles and obligations, could work in a seamless manner. The occupational physicians’ ethical confusion thus reflects the confusion in their ethical guidance.