Confidentiality is a core value of our profession. It is, as they say, bred in our bones. Yet confidentiality is not our only core value. When values central to our work conflict--that is, when we encounter an ethical dilemma--we look to the APA Ethics Code for guidance. Ethical Standards 4.06 and 4.07 illustrate how the code negotiates between competing values when psychologists disclose confidential information for treatment- and nontreatment-related purposes.
General Principle A, "Beneficence and Nonmaleficence," begins, "Psychologists strive to benefit those with whom they work..." General Principle E, Respect for People's Rights and Dignity, begins, "Psychologists respect...the rights of individuals to privacy, confidentiality, and self-determination." What happens when during the course of a treatment, a psychologist seeks a consultation, the effectiveness of which will depend on the psychologist disclosing identifying information about the client, and the client will not consent to the disclosure? This dilemma will be familiar to psychologists whose work is with clients who struggle with personality disorders. On the one hand, obtaining helpful consultations during the course of treatment is a primary way in which psychologists demonstrate beneficence. On the other hand, demonstrating respect for people's rights and dignity entails protecting confidentiality and preserving a client's autonomy. When your client does not want you to obtain a consultation that requires revealing identifying information, however helpful to the treatment the consultation may be, these two values crash head-on: What you judge to be in the best interest of your client's treatment is contrary to your client's wishes.
Ethical Standard 4.06 guides psychologists through the tension that arises between these competing values:
When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation....
The first clause of Standard 4.06 assigns priority to the competing values. The standard gives highest priority to beneficence: Above all, benefit your client. Put another way, it is permissible to disclose confidential information without your client's consent if the disclosure is necessary for the consultation to be effective.
In assigning priority to beneficence, Standard 4.06(2) remains protective of confidentiality by limiting the disclosure to necessary information. This clause echoes Standard 4.04(a):
4.04 MINIMIZING INTRUSIONS ON PRIVACY
(a) Psychologists include in written and oral reports and consultations, only information germane to the purpose for which the communication is made.
Both Standards 4.06(2) and 4.04(a) are reminiscent of the minimum necessary clause in HIPAA's privacy rule, which limits the information disclosed to the minimum necessary to achieve the purpose of the disclosure. (See HIPAA Privacy Rule, www.cms.hhs.gov/hipaa, section 164.502.)
Research, teaching and training are central to psychology. General Principle B, Fidelity and Responsibility, states, "Psychologists are aware of their professional and scientific responsibilities to society and to the specific communities in which they work." For many psychologists, advancing the science of psychology and preparing the next generation of psychologists are central to their professional lives and to their identity as psychologists. Ethical dilemmas involving confidentiality arise in each endeavor: We sometimes use confidential information to explain our work to our colleagues and to teach. Ethical Standard 4.07 governs how information is used for such purposes:
4.07 USE OF CONFIDENTIAL INFORMATION FOR DIDACTIC OR OTHER PURPOSES
Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so.
Like Ethical Standard 4.06, Standard 4.07 assigns priority to the values found in the General Principles. The standard recognizes that using confidential information has an important role in our scientific and training activities. Unlike Standard 4.06, Standard 4.07 gives highest priority to confidentiality and self-determination: Before using confidential, identifiable information for didactic purposes, psychologists must either obtain the individual's consent or disguise the information.
Note three additional points about Ethical Standards 4.06 and 4.07. First, the manner in which these two standards assign priority to values is consistent with the code's Preamble, which states that the code has as a goal "the welfare and protection of individuals and groups with whom psychologists work...." Beneficence has a direct relationship to a client's welfare and protection, while advancing science and teaching have a less direct connection. Given the code's Preamble, it makes sense that the code subordinates other values to beneficence.
Second, while Ethical Standard 4.07 gives a choice between obtaining consent or disguise, each of these alternatives has its own complexities. Asking a client permission to disclose confidential information will likely have an effect on the client, whether done during a treatment or after the treatment has ended. Psychologists should be sensitive to how they ask for permission, and how the client experiences both the request and the knowledge that personal information is to be disclosed. If a psychologist uses disguise, the psychologist may want to consider whether the particular disguise interferes with the scientific or didactic value of presenting the information. Certain disguises, for example, may detract or mislead from the very point the psychologist wishes to make by virtue of how the disguises interact with the clinical material. In addition, psychologists may want to consider how a client who learns of a presentation or publication would react to a disguise. As an example, clients have been known to react badly upon discovering that their gender, age or profession was altered, and have even concluded that the disguise reveals something about their psychologists' unspoken attitudes toward them.
Third, Standards 4.06 and 4.07 make a cleaner distinction between consultations and didactic presentations than is often found in real life. At many training institutions, for example, trainee and faculty presentations of clinical material achieve multiple goals: Such presentations teach, advance science and benefit the client. Careful editing and thoughtful supervision can often minimize the amount of identifiable information disclosed.
Disclosing confidential information involves values and serves goals that are fundamental to psychology. Ethical dilemmas arise not by virtue of a flaw or defect in our profession; they are rather a comment on the richness and complexity of what we do. The Ethics Code negotiates between conflicting values and assists in resolving ethical dilemmas in a manner that enhances our clinical judgment and supports a thoughtful approach to our clients and our work.