Confidentiality has its roots in the human practice of sharing and keeping secrets (Bok). For children, the desire to keep a secret is a manifestation of an emerging sense of self; the desire to share a secret stems from a need to retain or establish intimate relationships with others (Ekstein and Caruth). The willingness to share secrets presupposes an implicit trust or an explicit promise that they will be dept. Keeping and sharing secrets is a more complex social practice among adults. Some adults keep secrets simply to preserve their personal privacy; others may have something illegal or immoral to hide. Some persons do not reveal private thoughts, feelings, or behavior for fear of embarrassment, exploitation, stigmatization, or discrimination. Still others feel a need to disclose secrets to others to help resolve emotional conflicts or seek solutions to problems arising out of interpersonal relationships. The sharing and keeping of secrets among friends, for instance, creates a context in which ethical issues concerning promises, trust, loyalty, and interests of others may come into conflict. For example, I may promise a friend to keep a secret that she feels an urgent need to tell me. She trusts me not to tell anyone else about her revelation. Out of loyalty to my friend, I promise in advance to keep her secret. But I am thrown into a moral conflict when she unexpectedly discloses her impulse and plan to kill a family member who she believes is plotting against her. I realize that my obligations to keep my promise and preserve loyalty and trust conflict with a desire, if not a responsibility, to prevent my friend's harm to herself as well as serious harm to another. Do I preserve confidentiality or protect others? Similar ethical conflicts arise for health professionals and their clients or patients.

The following discussion clarifies the concept of confidentiality and the related ideas of privacy and privileged communication in healthcare settings. The rights of clients/ patients and the responsibilities of health professionals to their clients, their professions, and society bring out key ethical issues. Legal regulations both protect and limit confidentiality, sometimes in ways that create ethical conflicts for clients as well as professionals. In healthcare contexts neither absolute protection nor total abandonment of confidentiality is plausible. Yet sometimes it is uncertain where boundaries should be drawn because legitimate interests come into conflict. Personal privacy, professional integrity, effective care, economic considerations, and public health and safety influence both general policies and specific practices concerning confidentiality.

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Anxiety and Depression 101

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