The Oath is most unlikely to have originated in the Hippocratic school. Probably it came from Pythagoreans who, like Christians today, were committed to respect for human life and the value of people as individuals. Christians adopted the Oath and a version 'from the Oath according to Hippocrates in so far as a Christian may swear it, was probably written sometime before the third century AD. St Jerome had some familiarity with it and advised priests 'to keep your tongue chaste as well as your eyes'.
We should note however that the requirement of confidentiality is not an absolute one. Most doctors find it more convenient simply not to discuss anything about their work for fear of revealing something which should be kept secret. The Oath however invites doctors to make a judgment. The fact that someone is engaged in illegal activity may be something which 'ought' to be divulged. At one stage the British Medical Association believed that confidentiality was absolute but this became increasingly untenable. Nowadays doctors are expected to make such judgments and to do so in a climate in which confidentiality is under open assault.
The Bible and personal identity
In the very first chapter of the Bible we are taught that man is made in the image and likeness of God. If I am made in his image than I must have personal worth and value as an individual. Similarly everyone must have individual worth and value. Surely we are called upon to protect that individuality and to avoid anything which might weaken it. Disclosing information about individuals weakens them.
Israel grew up in a culture which believed that even one's name revealed information about the individual. God's name itself ought not to be misused for fear of reducing the glory of his majesty. Throughout the Old Testament there are examples where knowledge gained about a person was thought to diminish the individual and to create power over him.
In our own day it is fashionable to reveal juicy titbits about the private lives of famous men and women. Can we seriously deny that this diminishes their stature? Has the monarchy been strengthened by the activities of the tabloid newspapers? Are the achievements of various politicians enhanced by knowledge about their sexual activities?
Knowledge of a person's medical history can similarly result in inappropriate judgments being made which reduce the patient as an individual. Towards the end of his life a member of my own family talked much about the frustration he felt in discussing current symptoms with his new general practitioner by the frequent reference to the entry in his medical notes about a depressive illness 20 years previously. I know that inappropriate judgments have been made about my own professional value and work potential simply because I once suffered a cardiac arrest (from which I was successfully resuscitated!)
Trust in the doctor-patient relationship
It is essential if an accurate diagnosis is to be made that patients disclose to us all the facts which may be relevant to the diagnosis. Since, by definition, patients cannot know which facts are relevant or irrelevant, the doctor must gently persuade them to reveal as much about themselves as possible. The more information the doctor has the more reliable the diagnosis is likely to be. A patient may present to the doctor with disturbed bowel habit. The doctor can treat the patient for some kind of bowel disorder. The patient may however be experiencing a crisis in family relationships which has resulted in serious mental depression. It is this depression which accounts for the bowel disorder and which must be addressed if the matter is to be put right. Even the patient may not have made the connection. Yet unless the patient feels that he can trust the doctor not to reveal painful emotional secrets the true nature of the condition may remain undetected. Instead the patient could undergo a series of unnecessary and largely useless operations.
There is increasing interest in helping medical students and doctors to elicit such information from their patients but unless the doctors can be trusted to keep it confidential patients will not reveal it and the quality of their care will suffer. Confidentiality therefore is not a medical game left over from the school playground. It is a vital part of effective medical practice.
Threats to confidentiality
Threats to confidentiality are so serious because they are so insidious. Almost no one seriously challenges the need for confidentiality. Problems come when one is asked to decide whether these particular circumstances justify an exemption from the overriding commitment to confidentiality. In some circumstances they are considered to do so. In Northern Ireland doctors sometimes have to warn their patients not to disclose certain information because they (the doctors) may be under a legal obligation to reveal it. It may be very difficult, in for example psychiatry, to judge the precise moment when the patient is about to reveal damaging information.
1. Team work
In Hippocrates' day consultation was on an individual basis. Modern healthcare depends on team work and a variety of different healthcare workers may need to be involved. In some cases they bring particular skills which the doctor does not possess. In others they have a subsidiary contribution. Ideally the doctor would sort the information into groups feeding different facets to different members of the team. Yet even here other members of the team might benefit from the broader insights which the doctor has gained. Moreover this arrangement is not really practicable. Doctors are busy and it is far more convenient to share most of the information with the whole of the healthcare team even though some may have no clinical interest whatever in some of the information divulged. Some of these healthcare workers would be bound by ethical codes at least as tough and as capable of being monitored as the doctors. Others have none although, as government ministers rightly point out, those who have the money to do so can seek legal redress in the civil courts against anyone who causes them damage by releasing confidential information.
Moreover the membership of the healthcare team is also a matter for discussion. The Department of Health believes that all managers, administrators, secretaries and receptionists should enjoy equal access to the information 'within the NHS family'. This means that an individual's information could be shared with the largest workforce in Europe. It is highly unlikely that the patient realised this when he volunteered this 'private' information to the doctor!
Some members of the team may specifically reject the obligation to confidentiality. Although it is recommended that the police should attend child abuse case conferences, it is also pointed out that they may decide to use the information independently of the rest of the team and institute criminal proceedings.
All healthcare workers need to be taught and this is often best done either by observing an experienced practitioner at work or undertaking history taking and other clinical activities under (limited) supervision. Patients may be unaware of the precise status of the student and the healthcare setting rarely creates an atmosphere in which the patients feel they have a totally free choice in the matter.
Video-taping clinical consultations has been shown to be an effective way of improving consultation skills among doctors. It does however create enormous problems of confidentiality since there is virtually no control over who may see the video tape; there are no practical restrictions on copying the tape; and no opportunity for patients subsequently to change their minds The fact that some of us feel embarrassment when our parents show the baby snaps to our intended partners surely implies that attitudes do change over time concerning what we are prepared for others to see.
In all of these cases a breach of confidentiality will produce real benefits Must the patient always be consulted? Can consent ever genuinely be free? Are we prepared to respect a patient's wish to refuse consent and keep the material confidential? Are we prepared to provide healthcare within such very restricting requirements?
3. Automatic sata processing
The computer is revolutionising the practice of medicine but in doing so is posing the greatest threat of all. The inefficiency of paper medical records is notorious. Even when available paper records only give details of healthcare in that Institution and often not all episodes of that either. The technology now exists for the whole of the patient's medical history including every consultation, every investigation and eventually a genetic profile, to be included on a personal 'smartcard' which the individual could carry with them. The health benefits are enormous. Even if the patient arrived unconscious in the casualty department the doctor could have access to a total health profile including current medication and drug sensitivities. Experiments are currently under way in Germany and elsewhere. In the United Kingdom a system is being developed based on a unique NHS number to computerise all health information by the year 2000. Information can then be transmitted at the flick of a switch throughout the 'NHS family'.
The dangers are equally immense. First of all the system will require a unique identifier creating a personal identity card which has only previously existed in this country in war time. Secondly the information can be linked to other information such as tax and benefit details, criminal records and driving licence information. Thirdly, we cannot assume that governments will always be beneficent and altruistic. The Bible warns us that Man and his institutions are corrupted by sin. One has only to reflect for a moment on what Adolf Hitler might have done with this database to understand its full implications.
What can be done?
When the true nature of the dangers is understood practical solutions can be addressed. Protection of privacy has to become a major political issue. It is not simply a matter of a few individuals being humiliated by the tabloid press, important though that is. It is the right of every individual to know that 'that which ought not to be divulged' will not be spread abroad. This right must be enshrined in legislation. Those given the privilege of confidential information must know that they have a personal duty to protect it.
Although Aristotle said that 'what the law does not prescribe it forbids', the statute law must specifically forbid breaches of confidentiality. In my opinion the progressive retreat from this position over the last ten years by the government is one of the most sinister acts among a most astonishing catalogue of injustice, incompetence and progressive decline in moral standards in public life. Indeed this very decline should be a timely reminder of the dangers we face and why we should obey the New Testament injunction to pray for governments and those in public office.
It is silly to suggest that we should try to turn back the clock and resist the new methods of work and their new technology. They have so much to offer us that is good. We need to educate the profession to the dangers; recover the standards of ethics by which Western Medicine has tried to live for most of the last 2,000 years; and campaign for politicians to introduce the protective measures necessary to ensure that technology remains our servant and does not become our master. The strange symbolism of the book of Revelation shows very clearly what the end result will otherwise be. St John did not have a smartcard but he understood the danger of state systems blotting out individuality. For him, it was the mark of the beast'.