Confidentiality, consent and autonomy in the physician-patient relationship

In the practice of medicine there has long been a conflict between patient management and respect for patient autonomy. In recent years this conflict has taken on a new form as patient management has increasingly been shifted from physicians to insurers, employers, and health care bureaucracies. The consequence has been a diminshment of both physician and patient autonomy and a parallel diminishment of medical record confidentiality. Although the new managers pay lip service to the rights of patients to confidentiality of their records, in fact they advocate very liberal medical records access policies. They argue that a wide range of parties has a need to know the c ontents of individually identifiable medical records in order to control co sts, promote quality of care, and undertake research in the public interest . Broad interpretations of the need to know, however, are at odds with stri ct interpretations of the right to confidentiality. Strict confidentiality policies require that, with few exceptions, patient consent be obtained whe never a patient's record is used outside the treatment context. The traditi onal criterion for overriding the consent requirement has been that without the override some harm would directly result. This rule is now challenged by the claim that patients have a duty to make their records available for a wide range of research and public health purposes. The longstanding tensi on between physician responsibility for patient welfare and respect for pat ient autonomy is being replaced by a debatable requirement that both physic ian and patient autonomy be subordinated to the goals of data collection an d analysis.