Case-Based Ethical Argument
A moral dilemma in the emergency room: Confidentiality and domestic violence Jenkin, 2006
Julia Wadolowska
Dana Harrison

A patient presents to the ED with left arm fracture, and reports that the injury is secondary to a fall. On evaluation of x-ray, it is apparent to the nurse that the break pattern is inconsistent with her claim of cause. The woman divulges that the injury was in fact sustained three hours prior, during an altercation with her husband, during which her husband struck her. Patient denies that her children were or have ever been injured at the hands of her husband, however she does note they were present at time of incident. The patient has explicitly requested that nurse not document or relay true cause of injury to the physician or other members of her medical team. Of note, the patient and her husband are employees of the hospital where she is presently being evaluated. (Jenkin, 2006)

The ethical dilemma which is presented here asks that we consider whether the nurse disregard the patient’s request and disclose the true nature of her injuries, or alternatively, adhere to the patient’s stated wishes and observe patient confidentiality.  To address this, we can turn to the principles of autonomy and nonmaleficence. Autonomy is defined as a patient’s right to make her own decisions. Nonmaleficence is an obligation to minimize harm. By way of autonomy and nonmaleficence, we would argue that the nurse should not disclose to the medical team the true nature of the patient’s injuries, and by doing so, uphold the principle of confidentiality.

The proposed course of action, non-disclosure, can be first and foremost justified through the principle of autonomy by way of free action and effective deliberation. Autonomy is defined as a patient’s right to make her own decisions and can be considered within the framework of free action, effective deliberation, moral reflection and authenticity. (Yeo et al., Concepts and Cases in Nursing Ethics, 2010) Free action refers to the ability to accept or refuse a proposed course of action, including treatment. Effective deliberation is the process by which one has weighed the pros and cons so as to rationally reason through a decision. The patient has acted with autonomy and executed free action by first disclosing to the nurse, and then by explicitly stating her request for non-disclosure in documentation. To further promote the patient’s autonomy, we can also establish that the patient’s decision-making capacity, and thus her ability to effectively deliberate, is fully intact. The patient has weighed the factors involved in non-disclosure, not only as they apply to herself, but to her family. This includes the safety of her children, whom she has placed in the care of their grandmother during her evaluation, and the impact the disclosure would have on her husband’s career.

Nonmaleficence is the cornerstone of medical practice. It refers to the obligation to not inflict intentional harm, and “to impose no unnecessary or unacceptable burden.” (AAPA, Code of Ethics, 2013) Here we must consider what form harm itself can take. While withholding medically necessary treatment may be a relatively straightforward type of harm to identify, triggering an episode of domestic violence is less predictable. Documentation of the incident may introduce an unexpected risk of harm. We favor acting with nonmaleficence, that is, non-disclosure, in the hopes of preventing instigation. While the husband may escalate again regardless, the medical team should certainly not be the source that leads to another provocation.

Confidentiality in and of itself can also serve to prevent undue harm. The practice of confidentiality involves handling information in such a way as to preserve elements of trust in a patient-provider relationship. (Kirk, Confidentiality, 2015) By adhering to confidentiality, we are not just establishing trust between nurse and patient but instituting a trust in the patient herself. In her request for nondisclosure emerges an appreciation of her own surroundings and awareness of danger. There is a particular reason that the patient is requesting to withhold information, whatever that may be, and without appreciating the fullest picture of her situation, we cannot with any certainty draw the conclusion that taking action against her wishes would in fact not cause further harm. (Kirk, 2015) For instance, as mentioned above, the patient expressed concern for how disclosure would impact her husband’s job, the harmful consequences of which, should he lose his job, are not entirely known. Or, in a different line of thinking, her self-worth may be compromised and fractured, and she may fear judgement and isolation should her situation be revealed.

Conversely, by way of beneficence, it could be argued that disclosure of the incident would benefit the patient by facilitating her removal from the domestic violence situation, enable proper care and evaluation in the moment, as well as promote the well-being of her children. The patient would be thoroughly examined and treated, and the risk of harm from her husband hypothetically lessened. Her children would also be safer if they were removed from the situation. Looking solely at the principle of beneficence then, it would seem that disclosure would lead to more benefit for the patient and her children than nondisclosure.

In the case of domestic violence, a thorough plan and preparation must be made in order to leave the abuser. She must arrive at a place of physical and emotional safety before she can remove herself from the toxic situation, and it would be dangerous to hasten this process. Safety is therefore not guaranteed. Furthermore, while it can be said that the patient’s sense of autonomy is already compromised within the marriage itself, disclosure would minimize this even further. Violation of autonomy could lead to distrust in medical professionals, causing the patient to not seek medical help in the future. Disclosure in medical records, legal action taken, and possible chatter amongst colleagues could also lead to an escalation in violence. This would negate the benefit that was intended. Honoring patient autonomy is paramount, while minimizing harm is the safer course of action for the patient.

Respecting patient autonomy and minimizing harm by acting with nonmaleficence are key to supporting non-disclosure and can be weighed more heavily that an argument in favor of disclosure. The patient has clearly stated a choice, and due to the patient having decision-making capacity, that choice should be honored. The patient’s choice does not affect the quality of medical care the patient receives. The patient has also shown that she deliberated about her choice, mentioning the effects it may have on her husband’s job, and ensuring the safety of her children while she is not able to look after them. Further, the patient’s safety, as she perceives it, is assured through reducing harm via confidentiality.  Not disclosing the true nature of the patient’s injuries means that her husband will not be further provoked to harm her beyond what he already does. The patient is aware that the violence is an issue she needs to deal with but wants to minimize harm in the time being. The husband may retaliate and cause more harm if law enforcement were to be involved or if he were being scrutinized by his colleagues, which negates the argument of beneficence. Not disclosing could provide time for the patient to plan and prepare while not instigating more violence.