Reflections on Confidentiality

In modern health care, there’s a need for all members of the team caring for a patient to communicate effectively. That includes pastoral care staff as well as medical and nursing staff. How that communication occurs can vary from institution to institution, usually including some mix of written notes in the patient’s chart and direct verbal communication.

For all members of the care team there exists a general, shared responsibility to respect and protect the privacy of the patient, but the chart also serves as the legal record of the patient’s care, and can include highly sensitive information. Civil law may require the reporting of some details concerning the patient, such as when there’s a situation of risk to public health or a suspicion of physical or sexual abuse. The entire chart may be reviewed by third parties such as insurers, be released to others with the permission of the patient or family member, or end up being used in a civil or criminal court case. Charted as well as verbal information can result in damage to relationships, loss of health care coverage, or discrimination of various kinds. There can be serious ethical issues, not only in what a member of the care team charts personally, but also in what is reported in someone else’s charting.

Ethical standards regarding confidentiality vary from one profession to another, and the public may commonly expect a much different standard of privacy than is actually the case. That is especially true when it comes to religious leaders or to those entrusted by a religious group with the provision of pastoral care. A particular patient may not be aware of the health care implications of what they consider a religious problem or a family issue, and may view the passing on of details as a form of betrayal. A relative may view the patient’s airing of relational problems as betrayal by the patient. A particular staff member, regardless of profession, may have a tendency toward gossip, an intrusive curiosity about the private details of the lives of others, or simply an inability to appropriately sort what is and is not relevant to someone’s care.

The best practical advice I could give is to directly discuss issues of privacy with the patient if there’s any sense that the patient’s expectations may be different from yours. Even at the time a sensitive issue arises in conversation with the patient, you can avoid many problems by simply saying “I think that the rest of the staff (or the doctor, or the nurse, etc.) really should be made aware of that if they aren’t already. What do you think?” Situations that really are not relevant to the patient’s care should be considered unique pastoral communications and neither be noted nor passed on.

Specific difficulties can occur when someone representing one religious group comes into contact with someone from another religious group. There may be seriously divergent understanding and expectations.

For example, the strictest form of confidentiality that I’m aware of occurs with the Catholic Sacrament of Penance, and is called the “seal of confession.” To the extent that it’s humanly possible, after the celebration of the Sacrament the priest regards any information that was communicated as never having occurred. Without free and direct permission from the person it may not be used for later counseling, future contacts with the person, etc. No situation ever justifies violating that confidentiality, and no court, law, or person is seen as having any authority that could force a breaking of the seal of privacy.

As an anecdote, a psychiatrist once referred someone who told him that he wanted to see a priest. Afterward, if the psychiatrist happened to see me he’d come over with a herd of medical students and residents and begin raving about how years of problems had cleared up as a result of one contact. He was trying to make the point that working together was the most effective model for patient care. All I could keep telling him was that there was nothing I could say, even to acknowledge that the patient had talked about his problems. Then a few days later it would happen again. The conversation had apparently been relayed by the patient to the psychiatrist, but I could in no way presume that I was released from secrecy.

A general application of the same level of privacy may occur when a Catholic has contact with a priest and communicates especially sensitive information precisely and only because the other person is a priest. Someone may expect the same level of confidentiality from a Catholic deacon, a parish staff person, or a non-ordained hospital or nursing home Catholic chaplain. That expectation or transfer of the “seal of confession” privacy to a non-sacramental situation may be only on the part of the patient. Again, if there’s any significant doubt about the patient’s expectation, it should be clarified.

Someone representing a religious group may also have the equivalent of a “counseling” relationship, such as would exist with other professionals such as therapists, psychiatrists, or social workers. In that context discussion with other professionals in service of the patient would be routine and expected. Where there is uncertainty about whether someone would consent to a specific contact, a verbal permission would ordinarily be sought. Usually in similar situations therapists, psychiatrists, and social workers would obtain a signed, specific permission.

There can be situations when someone may specifically seek out a Catholic priest rather than their own minister to discuss an issue, seeking the absolute confidentiality that they associate with priests. I think that it’s important to be sensitive to that expectation. For example, a Baptist patient might ask to talk to a Catholic priest and directly state that they’re seeking that full privacy. The priest has the choice of either continuing or refusing the discussion. The patient might then state that she’s planning suicide that night, in the hospital, and wants to talk about the idea of going to Heaven or Hell. The end result may well be that the patient decides to allow referral to a psychiatrist, or decides to discuss it with other staff, or chooses to postpone the suicide attempt. If the patient continues in her plan, however, no chart note could be made, no other staff could be alerted, etc.

In contacts with Catholics by representatives of other religious groups, there’s also a need for special sensitivity. A Catholic patient may expect a higher level of confidentiality than would ordinarily be the case. For example, a Protestant minister sees a Catholic patient on a psychiatric unit. The patient states that she wants to “confess” and says that she feels comfortable with the minister. She chooses to see him rather than be referred to a Catholic chaplain. The patient then relates information that is highly sensitive and it’s clear that she would be very embarrassed for others to be aware of it. The information at least possibly would be helpful to medical and other staff in treating the patient. The minister leaves the patient and then summarizes the information in the chart, including the most embarrassing details.

The minister, seeing himself as staff, treated all information as appropriate for other staff. The patient, in my opinion, would have expected and based her contact with him on the understanding that her revelations would be shared with no one.

As a principle, I think there’s a special responsibility for pastoral care staff to clarify what kinds of information will and will not be passed on to other staff, family members, other chaplains, etc. Any time there’s evidence of confusion the issue should be addressed, and when a situation by its nature appears likely to involve differing expectations there should also be discussion.

For myself, when I would see patients in the hospital with psychiatric problems I always reviewed charting policy, repeatedly if necessary. I’d state that any discussion that would be outside of that usual practice would need my agreement in advance. That worked very well not only for Catholic patients but for those of other faiths as well.

Thankfully, not just with patients having mental health problems but with other patients as well, issues are easily cleared up if care is taken to do so. In fact, most conversations with patients don’t involve highly sensitive material, or it’s well-known already to staff, or really isn’t relevant to the patient’s hospitalization.

A unique difficulty can arise when someone is representing a religious group, but also has a non-theological degree or licensing from the State. Acceptance of that degree or license may require specific actions or reporting in specific situations. It may be necessary to make the role or relationship very clear to a patient or family.

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Last Revised 08/14/00