The Case of Megan and Ken: Confidentiality of a Diagnosis 

Bioethics Forum 14 (3/4), Fall/Winter 1998

Case compiled by Helen Emmott, RN, program consultant; questions posed by Rosemary Flanigan, director of ethics committee education and training, Midwest Bioethics Center, Kansas City, Missouri.

Megan and Ken have been married for twenty-two years. They have three girls, the youngest, Katie, graduates from high school this coming spring. The older two girls are away at college. The last five years have been difficult for Megan and Ken, their relationship held together through their commitment to get the children launched before going their separate ways. To others who know them, they are a model all-American family. Ken is a successful insurance executive; Megan is completing her master's degree in social work. It would be hard to imagine that they sleep in separate rooms, waiting for the last child to leave the nest. Megan has dedicated herself to preparing for independence (emotional and financial). Everything is rocking along as planned until Megan goes for a long-needed physical at her gynecologist's office.

Dr. Johnson completes Megan's physical examination and scolds her for not having been to see him for almost five years. She is surprised to discover that time has gone by so quickly and realizes that her own health has been at the bottom of the list for quite some time. Dr. Johnson tells Megan that she has some fibroid breast tissue, not unusual for a forty-six year old woman. He also reminds her that she is long overdue for a baseline mammogram. He hands her the check-out slip, tells her he will call if any of the lab or Pap results are out of the ordinary, and requests that she have his office assistant schedule the mammogram. Megan schedules the mammogram for after the first of the year. She has finals, college trips with Katie, and the holidays facing her in the next three months.

Megan follows routine instructions to prepare for the mammogram, no deodorant, no caffeine. She does not tell Ken that she is having the test done. Why should she? Only five more months and they will do what they should have done years ago - divorce. The x-ray is quick and noninvasive, and she waits to dress while a radiologist views the films. The technician returns and says that Dr. Smith would like to do a quick sonogram to further evaluate the "lumpy" tissue in her right breast, assuring her, however, that it is most likely fibroid tissue. Megan looks at her watch; she has class in half an hour. Once again, the procedure is painless and quick, but the radiologist indicates further concern after sonography. He will contact Dr. Johnson, and they will let her know.

Megan is shocked to receive a call from Dr. Johnson that evening. She will need to be scheduled for an outpatient procedure at the hospital as soon as possible. She will have medication and will need a driver to take her home. She is not upset by the procedure, but is puzzled about the required driver. After considering Katie (Megan doesn't want to alarm her), her mother (in frail health), and best friend Betty (she teaches), she realizes that Ken is her last and only option, unless she takes a cab. Ken agrees to take her Thursday morning at 6:00 A.M. He asks her if she thinks he can make it to the office by ten. The anesthesiologist and Dr. Johnson talk to Ken and Megan in the holding area, explaining the details of the procedure and advising Megan that she will be "groggy" for a while and should not drive all day.

And so she was. Ken took her home, but he did rush to the office as he had planned. He stayed with her and even offered to make her some soup. She refused and said she needed to try and get some paper work completed for class the following day. Ken then insisted that they talk and told her that her biopsy had been positive. She has breast cancer. Dr. Johnson had told Ken while Megan was in the recovery room. Ken went on to say that they had some hard decisions to make, but Megan didn't hear a word he said. Her mind raced. The doctor had told her husband her diagnosis. Megan never imagined that her doctor would give her diagnosis to anyone but her.

 

 

Questions:

  • Human relationships such as love, friendship, and trust depend upon an individual's control over information about oneself and about access to that information. Think of examples in everyday life.

 

  • The right of confidentiality can be justified by utilitarian arguments and by a principle of ethics (autonomy, especially in respect to privacy). How can both kinds of arguments proceed?

 

  • Yet we know that confidentiality is not an absolute value. How does one justify breaking a confidence or sharing confidential matters?

 

  • Physicians and other health care providers adopt patterns of behavior that sometimes slip easily into bad habits. No doubt Megan's physician presumed that she would want Ken to know the outcome of the procedure. How do such habits establish themselves in practice and how are they changed?

 

  • How can a health care system safeguard the ethical right of confidentiality?

 

  • Are privacy and confidentiality more or less at risk today in health care delivery and why?

 

  • What consequences are likely to flow from this breach of confidence?

 

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