Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we seek an expert ruling.
Last week, you voted on changing a patient's health record at her request. Here are the results:
Should the doctor use this method to remove the accurate information from the patient's chart?
Yes: 16%
No: 84%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his book, :
Prior to the 1970s, many healthcare professionals looked askance at anyone requesting access to their own medical records -- fearing that patients would generally fail to understand the contents. Concerns over litigation, the loss of medical mystique, and convenience likely played a role in such secrecy as well.
Since 1996, HIPAA has guaranteed patients the right to view their medical charts within 30 days. Many state laws require even more immediate access. The federal statute also gives patients the opportunity to append a "statement of disagreement" to their medical record if they object to any of its contents. Such statements may prove of value when there is a genuine dispute over facts. Yet in cases where the patient's concerns are for privacy, rather than accuracy, such a statement is of little value.
As a general rule, hospitals limit employee access to medical records to individuals directly involved in a patient's care. However, policing access can prove challenging, especially in the era of EMRs, and enforcement often occurs only after the fact. Firing a worker who illegally accessed and shared private information may prove little comfort to a patient whose secrets have already been divulged.
In this scenario, the patient appears to have sincere concerns for her personal safety; she is frightened that her partner's friends may access her records without authority and reveal the contents to him. She may also fear that the secrets she related to the doctor could be used against her partner in court -- which is likely permissible in certain states and under federal evidence rules.
Many hospitals allow celebrity patients, and others with compelling needs, to register under aliases. It is not clear whether the doctor's hospital offers such an option to patients like this one, or if it did, whether doing so would genuinely protect her from the staff members whom she fears. Few, if any, hospitals allow patients to opt out of the EMR entirely, and all physicians are required by law to keep records of patient encounters. In fact, failure to keep an adequate medical record is grounds for losing one's license in many states.
The purpose of the medical record is to be accurate and comprehensive, because a more complete record will lead to better patient care. One can imagine other patients requesting that providers delete information related to drug use, mental health diagnoses, or reproductive services from their records -- but also the serious consequences that might result from such willful omissions. Not knowing that a patient takes psychiatric medications, for instance, might lead an emergency room physician to prescribe an incompatible remedy that could prove lethal.
While physicians are wise to display some discretion in what they document, such as excluding a gratuitous insult that a patient offers about his mother-in-law, there are significant consequences to excluding medically pertinent data.
In this patient's case, one can easily envision her, at a future date, needing evidence of her partner's conduct in a custody battle or when seeking an order of protection. Or she might show up at the hospital unconscious with worse injuries the following week, and not knowing her abuse history, the staff might leave her with her partner unsupervised -- affording him an opportunity to hurt her again. Unfortunately, either honoring or refusing the patient's request might pose a significant future risk to her well-being.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
Check out some of our past Ethics Consult cases:
Force-Feed Prisoner on Hunger Strike?