Problem: Does the organization have the legal right and ethical authority to disclose Ms. Wallace's personal health information without her knowing and voluntary consent?
Vulnerable Population: Mental Health and Intellectually Disabled
You are the Senior Administrator in a large hospital's Physical Therapy Department. A Physical Therapy patient, Lisa Wallace, is a thirty-nine-year-old divorced mother of two young children ages five and six, who has been coming for physical therapy for the past six months. Lisa is undergoing physical therapy because she was involved in a car accident. She was hit and dragged by a bus while crossing a street outside of the crosswalk. As a result, she sustained multiple injuries including bilateral fractured femurs, a crushed calcaneus, an L2 fracture, neck and shoulder sprain, and deep dermal wounds to the trunk that required skin grafting. Lisa is now able to ambulate independently, but she is not able to drive and relies on either her mother or her sister to get her to and from her appointments.
From talking with Lisa and Lisa's therapist, Renee, you've learned that she is also receiving therapy that includes scar management, and that she has become obsessed over her body image. She is worried about the permanent scarring from the accident and that she has not yet got her figure back after the birth of her children. She has mentioned that her mother and her sister both managed to sustain an upbeat attitude despite being "disfigured by mastectomies."
Lisa appears to enjoy coming to physical therapy and has been steadily reaching her goals, but you believe her progress has been slow compared to other, similarly situated patients.
You suspect that Lisa may be "intellectually disabled", as she sometimes lacks the ability to comprehend simple instructions or to have difficulty finding words or processing information when she communicates. Just last week, she tried to pay for her physical therapy session, even though you have told her numerous times that her insurance will be billed, and they will take care of it. And she is constantly wiping your counters every time she approaches them. Her therapy is scheduled for 45 minutes, but because she often appears confused, sessions can take up to 75 minutes, for which the providers are not able to bill the insurance company. Nonetheless, you have had good conversations with her over time during her check-in and check-out of her appointments, since she sometimes must wait up to 15 or 20 minutes before starting her physical therapy or she stays behind to chit chat about cartoon characters and dolphins or her kids. She has confided in you about many personal events, and items about her kids, such as she sometimes lets them go to school and forgets to comb their hair or brush their teeth. Nonetheless, she "appears" to be an exceptionally good mom and her face lights up when she talks about her kids. Lisa's medical record documents diagnoses of bipolar-manic depression and obsessive-compulsive behavior and, although not documented in her medical record, you've been told she has an IQ of 68 but she appears to you to be functional.
Recently, after Lisa's last physical therapy session with Renee, Lisa shared with you that her family practice doctor, Dr. Izzy discovered a small lump in her right breast. She stated that the doctor suggested that she make an appointment with an oncology provider right away for follow-up. You could sense that Lisa was distressed over this information and was extremely agitated. Nonetheless, she stated that she did not want Renee or anyone to know anything about what she confided with you. She said she would "kill herself" if she had to get a mastectomy or had any scars whatsoever on her breast as she can barely tolerate the scars on her body now.
Two months have passed since Lisa first discussed the discovery of the lump on her breast. Today, after her physical therapy session, Lisa admits to you that she has not yet gone to see a doctor and that the lump is getting bigger, but she doesn't want to discuss it anymore. Lisa was adamant that if she finds out that Renee knows, she will quit coming to physical therapy. She also stated that Dr. Izzy is also no longer her doctor, and she removed the doctor's handwritten notes from her medical record so no one in the Physical Therapy Department of the hospital would find out. This was possible because her former provider, Dr. Izzy did not use an electronic medical records system, preferring instead to hand-write his records and provide paper copies to his patients.
You think Lisa is not facing up to the realities of her situation and is not making sound choices about her health; especially given the immediate family history that she has shared with you about her mom and her sister's history of mastectomies. While you believe she may have reduced intellectual or mental capacity, you are unaware of any medical or legal determination that Lisa is medically or legally incompetent to make her own medical decisions.
On the last few visits, either Lisa's mom or her sister with her two small children has accompanied Lisa and has waited for her physical therapy to end. While waiting, her mom and sister have shared with you that Lisa seems more depressed than usual and that she is no longer doing the home physical therapy because she seems "just too weak" on some days. They are not aware of Lisa's most recent issue over the significant lump on her breast, but they know that something is wrong.
You are concerned about whether your knowledge of this sensitive medical information places you, Renee, and/or the hospital at any ethical or legal risk or liability. You have been advocating that the hospital establishes a Medical Ethics Committee, but, to date, they are still working on a policy to implement one. You are not sure what your next action or actions you should or should not take. You have decided to meet with your departmental staff, research the issues, and forward a decisional memorandum to your Senior Hospital Administrator seeking a determination on the issue of whether you can or should disclose or not disclose the Lisa's medical information.