When you visit your doctor, you expect that everything you tell him or her will remain confidential. The same applies to your medical records. While you accept that practice staff can access the details, you rightly expect that your medical history will not become a talking point in the local supermarket.
But there are situations where doctors, with your permission, break medical confidentiality. When you apply for a driving licence you present a medical form to your practitioner which he fills in, with or without an eye examination. Based on this information, the local licensing authority decides on your eligibility for different classes of driving licences.
The key to breaking medical confidentiality is that your permission is sought before the breach occurs. Your consent must also be informed, in other words the context and potential implications of releasing private medical information must be explained to you.
The insurance industry routinely requests information from family doctors. Private Medical Attendant reports, referred to as PMA's in the business, are used to assess your risk for life assurance, major loans and mortgages. The insurance industry uses a standard PMA questionnaire. It also uses standardised consent forms for you to fill in. A copy of your consent is then sent by the company along with the PMA report form, to your "usual medical attendant". There is no examination involved. All the doctor has to do is to pull out your chart or call up your computerised record and answer the specific questions laid out in the PMA form. The practitioner is paid an agreed fee for this service by the insurance company.
Dr Brian Meade, a GP in Kilmacud, Co Dublin, questioned this practice in a recent opinion piece in the doctors' newspaper, Medicine Weekly. In an article subtitled: "Has the medical profession sold its soul to insurance companies?", Dr Meade asks: "Do our patients realise that we may provide information to insurance companies about visits they have had to other doctors, about investigations (including HIV tests) they may have had, and medical information about other members of their family? Do they also understand that the insurance companies may keep a database of our patients' histories which they share with other insurance companies, even when our patients have been refused insurance cover, and no contract exists between the patient and the company?"
It must be pointed out that there is nothing illegal or underhand about this practice. The small print on the consent form authorises "any person or doctor who is in possession of any information regarding my health to disclose..." that information to the insurance company. It also states that information given to one company may be passed on to " other insurance companies".
Dr Meade questions the validity of the consent given in these circumstances. "How can it be considered to be 'informed' consent when in many cases patients do not realise the extent, nature and consequence of the information being sought by the insurance company concerning them?"
So, what is the legal position? I have consulted a recently published book, Clinical Practice and the Law, written by Dr Simon Mills who is both a barrister and a general practitioner. It states: "Consent should also be informed; it may be prudent to communicate to a patient the information to be disclosed, especially if there is anything in the history that may be contentious but is necessary for an accurate and complete report. Patients have a legal right, based on data protection legislation, to see any report that is prepared concerning them."
The issue may also be broader than just patients' rights. There is anecdotal evidence to suggest that some people are not reporting certain symptoms to their general practitioners in case it might be passed on to an insurance company and prevent them getting a loan or pension. One story concerns an insurance broker who attends one doctor when he is ill and another for regular check ups. The second GP has no knowledge of his medical problems and so returns impeccable PMA's when requested to do so by an insurance company.
Dr Meade has raised an important issue which requires debate on current practice. At the very least, it would seem wise that patients ask to see the completed PMA form before it is posted off, notwithstanding the blanket consent given to the insurance company. Doctors are not permitted to edit the information they possess - being selective about what they disclose to the insurance company is not an option. If the patient is not happy with its content, it may well be that they will elect not to pursue insurance cover. However, at least this approach represents true informed consent and the exercise of proper autonomy by the patient.
The alternative is to change the system so that all medical assessments for insurance companies are performed by independent medical practitioners, with no reference to the confidential data held by GPs.
I would welcome readers' comments on how to address this dilemma at mhouston@irish-times.ie