THE JOURNAL OF SCHOOL AND UNIVERSITY MEDICINE - Volume 7 Issue 3, July - September 2020

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MINORS RIGHT TO CONFIDENTIALITY AND LEGAL DEROGATIONS

Author: Irina Georgiana IOSIF, Maria ALUAS

Category: Medical

Abstract:

INTRODUCTION: The ethical dilemmas and legal challenges that physicians are facing in their daily practice have multiplied in recent years, and when the physician has to treat minor patients these challenges are complex: conflicts between minors and parents; conflicts between minors and representatives of the educational institution; how the superior good of the minor is defined and what are the criteria on the basis of which it is established; what are the legal regulations that must be taken into account as a matter of priority.

PURPOSE: In this article we aimed to illustrate the opinion and attitude of doctors and nurses, members of the Society of Physicians from Children and Young People’s Communities (SMCCT), to the problems of adolescents in school medicine offices, and their management.

MATERIAL AND METHODS: A question naire was distributed online, completely anonymous (distributed on the Facebook group of SMCCT mem bers, with the support of group administrators). The design of the study is descriptive, transversal. From 1.06.2020 to 20.06.2020.

RESULTS: We analyzed the responses of 95 participants, aged between 20 and 65 years: 20 con sultant physicians, 22 physicians and 53 general

nurses from across the country. The participants had to analyze a case, having to choose between three an swer options.

DISCUSSIONS: In this case, 42% of the par ticipants opted for the correct option. Of these, 45% are over 50 years old, 62% are general nurses, 8% are specialists and 30% are consultant physicians.

CONCLUSIONS: This article illustrates, start ing from a clinical case, specifi c features in the ap proach of minor patients in school medical offices. The emphasis is on the confi dentiality of minors, as well as on the identifi cation of ethical conflicts that may arise from the context in which the medical act takes place in school medical offi ces and on the complexity of identifying the correct line to follow in such situations.

Keywords: Minors, Confidentiality rights, Drugs abuse

Full Text:

Journal of School and University Medicine

or legal requirements in this regard. In medical prac tice it is essential that the patient be able to openly discuss with the doctor aspects related to his medical situation, having the guarantee that all the details will remain secret. Otherwise, the quality of the me dical act could be compromised, thus omitting details nece ssary for a diagnosis and for creating an appropriate treatment plan [1].

Historically, medicine was the fi rst profession required to maintain professional secrecy [2]. The ob ligation of confi dentiality was enunciated, for the fi rst time, in the Hippocratic Oath, in the 5th century B.C.: “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be pri vate.” [3] .

Over the centuries, the principle of confi den tiality has been adopted by Arab and Jewish medi cine, while in Western civilization, it has been little known due to the lack of organization of the medical profession. Since the eighteenth century, this Hippo cratic principle has generally been respected, being regulated in two different ways: deontologically and legally. In Anglo-Saxon society, medical secrecy is stipulated only in codes of ethics, and is not legally framed, according to British physicians J. Gregory and T. Percival: “discretion must be strictly observed only if circumstances so require,” and if the doctor were to testify in court, “he must tell the truth, all the truth and only the truth.” In France, the obligation to maintain medical secrecy was mentioned in the Penal Code in 1810, thus becoming more of a legal obli gation than a moral requirement. This was later con fi rmed by the codes of ethics [1].

Over time, the principle of confi dentiality has been taken up by most countries and has been in cluded in international ethical documents, such as the 1948 Geneva Declaration, which is an updated form of the Hippocratic Oath, that states that secrecy must be kept even after the patient’s death [4].

The International Code of Medical Ethics (AMM) also mentions the duty of the physician to maintain patient confi dentiality, referring to two situ ations in which its violation is accepted: if the pa tient’s consent is obtained or in cases where there is

an imminent danger to the patient or other persons’ lives, a danger that imposes a breach of confi dential ity for it’s resolution [5].

The deontological code of the Romanian Col lege of Physicians stipulates, in chapter III, the obli gation to maintain the medical secret, with some pe culiarities. Article 17 establishes the obligation for the

doctor to keep professional secrecy, as a form of re spect for privacy. In article 18 it is stipulated that the doctor has the duty to maintain confi dentiality even to family members or in the event that the person dies or ceases to be a patient. Articles 19 and 20 specify the exceptions to the rule, namely: at the request of the patient or in the case of derogations provided by law [6].

LEGAL EXCEPTIONS REGARDING CONFIDENTIALITY

Although medical secrecy is an obligation of the medical staff, both ethically and legally, it also has certain limitations, as the patient’s privilege some times confl icts with the public interest. Thus, there are a number of legal derogations that allow, in certain specifi c situations, the disclosure of medical secrecy. According to the legal regulations in force in Roma nia, these provisions are:

1. According to article 16 of Law 119/1996, if for certain reasons the parents cannot declare the birth of the child to the City Hall, this obligation falls on the doctor, medical staff or any other person who is aware of the birth of the child [7].

2. Article 35 of the same law, paragraph (1) highlights the doctor’s duty to issue and sign the me di cal certifi cate establishing the patient’s death, stat ing the cause of death. In the absence of a doctor, this responsibility will fall on a healthcare professional present [8].

3. Government Ordinance number 53 from 2000 mentions in article 1, paragraph (1) the fact that family doctors are obliged to ensure the vaccination of children according to the national immunization scheme, and in article 5 highlights their obligation to report, in accordance with the methodology of the

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Ministry of Health, all communicable and non-com municable diseases [9].

4. Law no. 319 from 14th of July 2016, article 27, paragraphs (2) and (3) indicates that any doc tor, including the occupational medicine doctor who is in a contractual relationship with the employer, has the duty to declare to the territorial public health directorate, respectively the municipality of Bucha rest, any suspicion of an occupational or related to the profession disease discovered during medical examinations [10].

5. Government Decision no. 589 from July 13th 2007 on establishing the methodology for reporting and collecting data for the surveillance of communi cable diseases implies the obligation of the doctor to complete the single fi le report of a case of communi cable disease, which must be registered by the county or Bucharest public health authority. Diseases that fall into this situation include HIV / AIDS, tuberculosis, tetanus, polio, syphilis, measles, hepatitis, botulism, anthrax, etc. [11].

6. Doctors responsible for medical examina tions for disability pensions have the obligation to re port both the new cases (monthly) and the evolution of cases that require periodic reviews (weekly) to the Territorial Pensions Institutions, which in turn report to the National House of Pensions. The data required are: the patient’s identity data, the diagnosis and the degree of disability in which he/she was placed (2).

7. Doctors from school medical offi ces, kinder gartens and universities have the task of performing regular epidemiological triage and reporting the re sults to the Public Health Directorate, in accordance with the Order of the Minister of Health, no. 653 from 2001 [12].

8. In the case of persons diagnosed with pathol ogies considered to be incompatible with driving, the doctor who diagnoses and cares for the patient (family doctor or other specialty doctor, such as neurologist, ophthalmologist, cardiologist) has the duty to refer the patient for a thorough examination to an expert comission which shall take the necessary measures for the safety of the population, including, in some cases, suspending the driver’s license until the condition is

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resolved. The incriminated conditions include diabe tes, some neurological, cardiovascular or ocular con ditions. This derogation is the subject of Government Emergency Ordinance no. 195 from 2002, article 22, paragraph (6) [13].

Other justifi ed breaches of confi dentiality may be considered: the use of interpreters in situations where the patient does not speak the same language as the healthcare professionals, in which case the in

terpreter must be aware that he or she has an obliga tion to maintain confi dentiality; the practice of medi cal students also involves the study of clinical cases, the students being subject to the rule of professional secrecy. Sometimes, during the process of diagno sis and treatment, more medical personnel should be aware of the patient’s condition, and outside the health facilities, relatives may need some data about patients in order to provide them with the care they need and sometimes to protect themselves. Another situation where a breach of confi dentiality is neces sary and justifi ed is that where the patient is a danger to those around him, when the doctor may have to inform those around him [14].

These derogations refer to exceptional situa tions, where information regarding the patient’s health is no longer related only to his privacy, but also to the safety of those around him. Also, in the case of epi demics, due to the high risk to which those from the whole community are exposed, the derogation from professional secrecy is justifi ed. At the same time, each case has its own particularity, and the doctor has the duty to weigh the risks to which the patient and those around him are subjected to. Exceptions from the rules or derogations do not generally raise ethical issues, but the patient must be informed of this act and its repercusions and his decision to allow or not to allow the doctor to disclose confi dential information must be respected [2].

In conclusion, the confi dentiality of medical in formation is seen as a fundamental right of the patient, being protected by both the law and the codes of med ical ethics. However, the regulations do not provide for the case of minor patients, but since minors have the right to be treated appropriately, we deduce that they enjoy the same rights as adults, their privacy must

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Journal of School and University Medicine

be protected as in the case of any patient, according to respect for human rights under international norms, such as the European Convention on Human Rights (ECHR, 1950).

PURPOSE. MATERIAL

AND METHODS

The purpose of this study is to illustrate the atti tude of doctors and nurses, members of the Society of Physicians from Children and Young People’s Com munities (SMCCT), in the face of medical problems of adolescents who adress the school medical offi ces, when maintaining patient confi dentiality is not as simple as it might seem.

The design of the study is descriptive, trans versal, and it was conducted from 01.06.2020 to 20.06.2020 by distributing a questionnaire online. The study does not include experimental research or clinical trials in minor patients. The questionnaire was completely anonymous, being distributed on the Facebook group of SMCCT members, being distrib uted with the support of the administrators of this group. The selection of study participants was made on the basis of inclusion and exclusion criteria with out discrimination of age, sex and work experience.

Inclusion criteria: consultant or specialist phy sicians and general nurses who work in school med ical offi ces across the country during the study and who are members of the online community (face book) SMCCT.

Exclusion criteria: other categories of staff working in these institutions were excluded from the study, such as: psychologists, social workers, teachers.

Sample size: The study involved 95 partici pants, of whom 94 were women and one man, aged between 20 and 65, of whom: 20 are consultant phy sicians, 22 are specialist physicians and 53 general nurses, located anywhere throughout the country.

The data collection was carried out over a pe riod of approximately 3 weeks, by distributing a two part questionnaire online.

The fi rst part contains demographic data, from which we found out: the gender and age of the partici pants; professional level and experience in the activity.

The second part highlights the ethical and legal aspects encountered in the practice of school medi cine, illustrated in six cases. Each case is inspired by medical practice, there are situations in which the doctor has to manage a wide range of problems, di lemmas and questions of various kinds: ethical, legal, social, cultural. The participants in the study had to choose between three different answers, being able to opt for only one, the one they consider correct.

In this article we will present the fi rst case contained in the questionnaire and the results we ob tained after evaluating the participants’ answers. We analyzed the case referring to the current legislation in force in Romania and in the European Union, as well as to the principles of medical ethics.

The next fi ve cases, their results and analysis, will be the subject of further articles which, with the goodwill of the editors, will appear in this publication.

Case 1: A 17-year-old patient has a syncopal episode during a football match. The young man has been playing in the junior team of the local sports center for 3 years, but it is the fi rst episode of this type. He is transported to the emergency unit, where after preliminary investigations, no organic abnor

malities are detected, but in the urine tests for drugs, the presence of amphetamines is detected. After fur ther discussion with the patient, he acknowledges that he occasionally consumes methamphetamines for its energizing and euphoric effects. Thus, the syncopal episode could be explained by an arrhythmia caused by an overdose. The patient asks the doctor not to in form the parents about the test results, fearing that they would forbid him to continue sports activities.

Possible answer options are:

a. You inform the parents about the patient’s health status and about the test results.

b. You inform the parents and you report the case to the competent authorities, as this is an issue about illicit drugs.

c. You inform only the patient about the serious consequences of substance use on the possibility of deteriorating long-term health, as well as the fact that the use of substances could affect a potential sports career.

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RESULTS

From the responses of the study participants,

we note that 42% chose “option b”, which we consid

ered to be correct; 41% chose variant a, only inform

ing parents; and 17% chose answer c, considering that

informing the patient is suffi cient (Image 1).

Fig. 3 – CAZUL 1 – Distribu?ia celor care au ales r?s

punsul corect, în func?ie de nivelul profesional

Most of the participants who answered cor

rectly have more than 5 years of experience in the

activity ( 95%), only 5% having less than 5 years of

experience (Image 4).

Fig. 1 – CAZUL 1 – R?spuns corect: b

Among the participants in the study who an

swered correctly, we can see that 7% are between 31

and 40 years old, 48% between 41 and 50 years old,

and 45% over 50 years old (Image 2).

Fig. 4 – CAZUL 1 – Distribu?ia celor care au ales r?s

punsul corect, în func?ie de experien?a în ac? vitate

DISCUSIONS

In Romania, the National Anti-Drug Strategy

was adopted through Government Decision number

461/2011 regarding the organization and functioning

Fig. 2 – CAZUL 1 – Distribu?ia celor care au ales r?s punsul corect, în func?ie de vârst?

Also, 62% of them are general nurses, 8% spe cialists and 30% consultant physicians (Image 3).

of the National Anti-Drug Agency (A.N.A.), an in stitution mandated to ensure the coordination, at na tional level, of the elaboration and implementation of response policies to the drug phenomenon, an insti tution which operates within the Ministry of Internal Affairs [15].

According to article 1 of Law no. 143 from July 26th 2000 on preventing and combating illicit drug traffi cking and use, methamphetamine is a high-risk drug. Article 4 of the same law stipulates in paragraph (1) the fact that the experimentation, production,

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Journal of School and University Medicine

cultivation, manufacture, extraction, processing, preparation or possession of dangerous drugs, for the purpose of self-consumption, without right, is punish able by a fi ne or imprisonment for 3 months to 2 years, and in paragraph (2) it is stated that in the case of high risk drugs, the penalty is imprisonment from 6 months to 3 years [16]. Therefore, our case is about a crimi nal offense, so there is an obligation to report the case to the competent authorities. In article 22 of the same law, it is provided that persons who use illegal drugs may be included, with their consent, in psychological

and social therapeutic reintegration programs (16). Also, the patient’s attitude obviously puts his health in danger. Methamphetamine is a syn thetic drug, part of a group of drugs called amphet amine-type stimulants, which comes in the form of tablets, powder or crystals. In terms of administra tion, it can be smoked, injected, snorted / inhaled or swallowed. The effects for which it is used include euphoria, joy and temporary increase in energy, help ing to increase physical or intellectual performance. After the euphoric effect has passed, consumers feel tired and hungry. The risks of short-term consumption include: tachypnea, tachycardia, hypertension, sweat ing, agitation and irritability; in case of an overdose, convulsions, seizures or even death from stroke, res piratory failure or heart failure may occur. In the long run, methamphetamine use leads to weight loss with malnutrition and psychological dependence. In case of chronic consumption, cessation of consumption is followed by a period of sleep and then depression [17]. Due to the numerous effects, both in the short and long term, we deduce that if the patient does not stop consuming, he puts his health and life in danger. As we are dealing with a minor, the parents or legal representatives must be informed about his con dition, about the dangers to which he is exposed to by practicing intense sports activities, but also about the regular consumption of amphetamines. However, the medical staff has no guarantee that the minor will stop using amphetamines, that the parents understood the seriousness of the situation and that they will be able

to face these challenges. In order to be sure that we have taken into account the well-being of our patient, even if his right to privacy is questioned, we will have to report the case to the police, who will refer the case to the Directorate for Organized Crime and Terror

ism. (DIICOT).

CONCLUSIONS

Medical practice has always aimed at the well-being of the patient. The physician must act in such a way as to integrate: the optimal therapeutic conduct, the patient’s preferences and wishes, the ethical and legal regulations in force. In the approach of the pediatric patient, this is a double challenge be

cause in the act of diagnosis and treatment is involved at least one third party: the patient’s parents or legal representative, which can hinder the decision-making process, their interests sometimes being contrary to the interests of the minor patient. This article illus

trates, by addressing a clinical case, specifi c features in the approach of minor patients in school medical offi ces. Emphasis was placed on the issue of adoles cents’ right to privacy, as well as on the identifi cation of ethical confl icts that may arise from the context in which the medical act takes place in school medical offi ces and on the complexity of identifying the cor rect path to follow in such situations. .

Practical implications

of the obtained results

From analysing the results, which refl ect the attitude of the medical staff towards the issue of juve nile privacy, we can see that it is not easy to respect the right to privacy of juvenile patients, nor the imple mentation of legal provisions and ethical principles. Doctors’ decisions are often made without analyzing all the consequences that may arise from them, being infl uenced both by the context and the location of the activity, as well as by the experience of the medical staff.

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1. Cipi B. Ethical, juridical and historical aspects of med ical confi dentiality. JAHR. 2012, 3(1): 139-146

2. Alua? M, Ana D. The relationship between maintain ing medical secrecy and malpractice in: Health Legislation. Bu cure?ti: Pro Universitaria; 2018.

3. Hippocratic Oath [Internet]. Available at https://www. nlm.nih.gov/hmd/greek/greek_oath.html accesed on 25.01.2020. 4. Curc?, GC. Medical ethic elements. Ethical guidelines in medical practice. Bioethics principles. Cluj-Napoca: Casa C?r?ii de ?tiin??; 2012.

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6. Code of Medical Deontology of the Romanian College of Physicians fron November 4th, published in the Offi cial Ga zette, Part I no. 981 of December 7, 2016, entered into force on January 6, 2017.

7. Law no. 119 of October 16, 1996 regarding the civil status documents, art. 16 republished in the Offi cial Gazette, Part I, no. 339 of May 18, 2012.

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9. Government Ordinance no. 53 on the obligation to re port diseases and carry out vaccinations. Published in the Offi cial Gazette Part I no. 42 of January 31, 2000, in force since March 31, 2000.

10. Law no. 319 of July 14, 2006 on safety and health at work, art. 27. Published in the Offi cial Gazette Part I no. 646 of July 26, 2006, in force since October 1, 2006.

11. Government Decision no. 589 of June 13, 2007 on establishing the methodology for reporting and collecting data for

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the surveillance of communicable diseases. Published in the Offi - cial Gazette no. 413 of June 20, 2007.

12. Order of the Minister of Health no. 653 of 2001 on the medical assistance of preschoolers, pupils and students. Published in the Offi cial Gazette Part I no. 777 of 5 December 2001, in force since 5 December 2001.

13. Government Emergency Ordinance no. 195 of 2002 on traffi c on public roads, art. 22, paragraph (6). Published in the Offi cial Gazette no. 670 of August 3, 2006. Article 22 modifi ed by Law 345 from December 27, 2018, published in the Offi cial Gazette no. 4 of January 3, 2019.

14. Ghelase M?. Bioethics. Craiova: Editura Universitar? Craiova; 2016.

15. Government Decision no. 461 of May 11, 2011 on the organization and functioning of the National Anti-Drug Agency, updated on July 21, 2015.

16. Law no. 143 of July 26, 2000 on preventing and com bating illicit drug traffi cking and consumption, art. 1, 4, 22. Pub lished in the Offi cial Gazette no. 362 of August 3, 2000. Updated and republished in the Offi cial Gazette no. 163 of March 6, 2014.

17. National Institute of Public Health, “Drugs” [In ternet], 2016. Text available at: http://insp.gov.ro/sites/cnepss/ wp-content/uploads/2016/01/Analiza-de-situatie-droguri -2016. pdf, accessed on 24.07.2020