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The Ethics of “Conditional” Confidentiality

*This workshop uses a Practice Model adapted from
Fisher, M.A. (2008). Protecting confidentiality rights:
The need for an ethical practice model. 
American Psychologist, 63, 1-13. doi: 10.1037/0003-066X.63.1.1
and
Fisher, M.A.  (2013). The Ethics of Conditional Confidentiality:
A Practice Model for Mental Health Professionals.
New York, Oxford University Press.  ISBN 9780199752201

INTRODUCTION: 
The ABCs of “Conditional” Confidentiality
Using an Ethical Practice Model to Protect Confidentiality Rights*

STEP 1. PREPARE
     A.  Understand patients’ rights and therapists’ ethical responsibilities in behalf of those rights
     B.  Decide what voluntary limits will be imposed on confidentiality in the practice setting
     C.  Learn the laws that can affect therapists’ ability to protect confidential information
     D.  Clarify own personal ethical position about confidentiality and its legal limits
     E.  Develop plan for ethical response to laws requiring therapists to disclose “involuntarily”
     F.  Choose reliable ethics consultants and legal consultants and use as needed
     G.  Devise informed consent forms that reflect these actual policies and intentions
     H.  Prepare to discuss confidentiality and its limits in understandable language

 STEP 2. TELL PROSPECTIVE PATIENTS THE TRUTH   (Inform Their Consent)
     A.  Inform prospective patients about potential limits that may be imposed on confidentiality  
     B.  Explain any roles or potential conflicts of interest that might affect confidentiality
     C.  Obtain informed patient’s consent to accept limits as a condition of receiving services
     D.  Reopen the conversation if patient’s circumstances, laws, or therapist’s intentions change

 STEP 3.  OBTAIN INFORMED CONSENT BEFORE DISCLOSING VOLUNTARILY
    A.  Disclose without patient consent only if legally unavoidable
     B.  Inform patient adequately about the content and implications of potential disclosures
     C.  Obtain and document the patient’s consent before disclosing 

STEP 4.  RESPOND ETHICALLY TO LEGAL DEMANDS FOR DISCLOSURE
    A.  Notify patient of pending legal requirement for a disclosure without patient’s consent
    B.  Respond ethically to legal obligations according to plan (from step 1,e above)
              1. Laws requiring therapists to initiate disclosures (e.g., reporting laws)
              2. Laws granting others access to patient information without patient consent
              3. Laws allowing recipients of information to redisclose without further patient consent 
              4. Exceptions to privilege in court cases
    C.  Limit disclosure to the extent legally possible, using protective laws when available

STEP 5.  AVOID THE PREVENTABLE  BREACHES OF CONFIDENTIALITY
     A.  Establish and maintain protective policies and procedures
     B.  Conduct staff training
     C.  Monitor note taking and record keeping practices
     D.  Avoid dual roles that might create conflicts of interest about confidentiality
     E.  Anticipate legal demands; empower patients to act protectively in their own behalf
     F.  Protect patient identity in presentations, research, consultations
     G.  Prepare a professional will to protect patient confidentiality in event of illness or death

STEP 6. TALK ABOUT CONFIDENTIALITY
    A. Model ethical practices about confidentiality; confront others’ unethical practices
    B. Provide peer consultation about confidentiality ethics
    C. Teach ethical practices to students, supervisees, employees
    D. Educate attorneys, judges, consumers and the public
    E. Lobby for legislative reform toward better legal protections of confidentiality

Learning Objectives:
1. To consider the ethical complications caused by placing “conditions” on confidentiality.
2. To learn an Ethical Practice Model that protects patients rights in the face of those conditions
3. To practice using that Model with hypothetical case vignettes and with situations from my own experience.