Read the full text of Dr. Reamer's comments below
Comments by Frederic G. Reamer, PhD
In my view, practitioners need to be concerned about disclosing any client-related details that would enable a reader to identify that person. Certainly, the most obvious examples include the client’s name, diagnoses, geographical location, actual initials, and so on.
I’ve read several Internet accounts of clinical cases that included, in my view, inappropriate detail that was not this explicit. The clinicians’ presentations included remarkably unique clinical circumstances and settings that might enable a reader to put 2 and 2 together to get 4, so to speak. Typically I recommend that practitioners be remarkably vague in their presentations and avoid any unique information that may lead to client identification. One useful rule, I think, is that the presentation should be such that even the client wouldn’t recognize himself or herself.
One can think about this issue in broad conceptual terms and with respect to specific ethical standards in the field. With regard to broad ethics concepts, I am concerned about the way that inappropriate disclosures of clients’ identifying information could violate clients’ right to privacy and their right to consent to disclosure of confidential information. I’m also concerned about possible conflicts of interest (for example, when the practitioner’s disclosure is self-serving) and the possibility that some practitioners may not fully appreciate the relevance of clients’ cultural and ethnic diversity, i.e., differences among clients with respect to the importance and implications of varying privacy norms. I’ve found that members of some cultural and ethnic groups feel much more strongly about privacy than others.
In my profession – social work – inappropriate disclosure of clients’ identifying information would violate two key “ethical principles” in the NASW Code of Ethics:
the dignity and worth of the person (“Social workers respect the inherent dignity and worth of the person. Social workers treat each person in a caring and respectful fashion.”)
Integrity (“Social workers behave in a trustworthy manner.”)
In addition, inappropriate disclosure of clients’ identifying information would violate a number of key “ethical standards” in the NASW Code of Ethics (selected excerpts below):
1.01 Commitment to Clients: Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary.
1.02 Self-Determination: Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals.
1.03 Informed Consent: (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent.
1.05 Cultural Competence and Social Diversity
(a) Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.
(b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups.
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
1.07 Privacy and Confidentiality
(a) Social workers should respect clients' right to privacy. Social workers should not solicit private information from clients unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply.
(b) Social workers may disclose confidential information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client.
(c) Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons.
(d) Social workers should inform clients, to the extent possible, about the disclosure of confidential information and the potential consequences, when feasible before the disclosure is made. This applies whether social workers disclose confidential information on the basis of a legal requirement or client consent.
(e) Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients' right to confidentiality. Social workers should review with clients circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship.
(i) Social workers should not discuss confidential information in any setting unless privacy can be ensured.
m) Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.
(p) Social workers should not disclose identifying information when discussing clients for teaching or training purposes unless the client has consented to disclosure of confidential information.
(q) Social workers should not disclose identifying information when discussing clients with consultants unless the client has consented to disclosure of confidential information or there is a compelling need for such disclosure.
2.05 Consultation
(c) When consulting with colleagues about clients, social workers should disclose the least amount of information necessary to achieve the purposes of the consultation.
In my opinion, clinicians must adhere to these ethical principles and standards. I think clients have the right to know, in general, that a clinician may share limited and disguised information with colleagues for consultation, supervision, and teaching purposes. The clinician can spell out her or his policy in the general information packet that most clinicians prepare for clients related to scheduling, emergencies, confidentiality, fees, and so on (see ethics standard 1.07[e] above). Clients then have an opportunity to raise questions about how clinicians handle disclosures, relevant circumstances and guidelines, etc. This is consistent with the principle of informed consent.
I have several additional observations based on my experience with Internet discussion sites that include clinicians and address clinical phenomena:
Clinicians who disclose clinically relevant details expose themselves to several risks. One possibility is that a client, or a client’s family member or “significant other,” will recognize him- or herself. This individual may feel harmed by the privacy breach and overexposure; in addition, the individual may file an ethics or legal complaint alleging that the practitioner failed to respect the individual’s privacy and harmed him or her emotionally as a consequence. Another possibility is that the overexposed individual will claim that his or her informed consent rights were violated, i.e., the clinician failed to adequately explain his/her policy around confidentiality, consultation, disclosure, and so on. Also, I think it’s possible that a client or other party could claim “breach of contract” if, in fact, the clinician didn’t honor their agreement about disclosure of identifying information.
I’m willing to believe that presentation of disguised material by a neutral third party (e.g., the Internet site moderator) can add a layer of insulation and protection, i.e., the information wouldn’t be linked directly to any single clinician. However, the clinician involved in the case still bears a considerable burden, I think, to disguise the case material adequately. The moderator’s involvement doesn’t get the clinician off that hook. I’d keep in mind the possibility that the names of clinicians associated with the discussion group may be public; savvy readers might put 2 and 2 together
Clinicians should use great care when they describe clients’ family members and acquaintances. Here too clinicians should be careful not to compromise these individuals’ privacy. Clearly this would be unethical, even if clinicians may not have any strict legal duty to third parties who are not clients.
Clinicians should be clear about using Internet discussions as a form of supervision as opposed to consultation. These two phenomena are different. Consultation can be very informal; further, the recipient of advice from a consultant is not necessarily expected to follow the advice. There’s no fiduciary duty. In contrast, supervision is generally considered a more formal arrangement with many more duties and obligations. Recipients of advice from a supervisor may be expected to follow it. The nature of the fiduciary duty – where the supervisor has oversight responsibility – is quite different. Moreover, supervision typically entails an agreement (often a formal agreement) that spells out expectations, responsibilities, goals, confidentiality, client notification, fees, and so on. Supervisors typically need to demonstrate their competence, experience, and expertise before taking on the supervisory role. Such is not the case with consultation. I think these issues are germane in Internet discussions as well as in more traditional forms of consultation and supervision.
In some ways, presentation of case material online is similar to presentations at professional conferences, symposia, in-service trainings, grand rounds, and in journal articles. One unique difference is that professional conferences, symposia, in-service trainings, and grand rounds typically limit attendance to professionals who are trained to respect client confidentiality and privacy. The general public typically isn’t invited to these sessions. I think the ethics stakes go up if the Internet site can be accessed by the general public (i.e., access isn’t restricted to those with professional education and training).
In principle, if employees or students disclose details inappropriately, the agency (employer or field instruction site) could be held responsible if there is evidence that the agency staff did not take adequate steps to address the issue with employees and students, develop reasonable policies, and have reasonable protocols to monitor disclosures (monitoring every communication would not be realistic, of course).
Clinicians would be wise to adhere to relevant HIPAA standards concerning disclosure of identifying information. In addition, they should carefully review relevant codes of ethics, regulations, statutes, and case.