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It is timely to
publish a collection of British perspectives on confidentiality. Legislators
are grappling with issues of privacy, access to medical records and justifiable
releases of confidential information. In Australia, new federal and state
statutes regulate the collection of, and access to information related to
health. In Canada, the ethics of mandated breach are vigorously debated. And in
the USA, the terrain beyond Tarasoff has fundamentally altered
In the United
Kingdom, pressures on confidentiality are felt from, on the one hand, the Human
Rights Act 1998; and, on the other, a blame culture which retrospectively
determines the causes of medical errors and publicises these. A frequent
finding is of poor communication between different agencies.
This book arose from
a conference on held in Sheffield in 1998. Nevertheless, it seems to have
avoided the faults of collections that collate disjointed papers but avoid the
words conference proceedings. The authors cover a number of fields, in
particular those of psychotherapy and psychoanalysis. Professions allied to
medicine, and legal contributors also contribute chapters, although it would
have been interesting to hear more of non-doctors, in particular describing
clinical scenarios specific to those disciplines.
The introduction is
by Bill Fulford. He identifies the challenges posed to practitioners and to
traditional bioethics, and successfully grounds the issue in clinical practice.
Fulford argues that the issues are best addressed not by regulation, but by
communication; and not by seeking universalisable action-guiding principles,
but by learning from casuistry and the values of service users.
The next three
chapters address adult services, and specifically suggest a number of realistic
vignettes which express problems of confidentiality in psychiatric practice. In
forensic psychiatry, community psychiatry and the doctor-patient relationship,
the authors explore ways of addressing breach of confidentiality, maintaining a
focus on awareness of ethical principles as well as legal consequences.
Child protection and
the status of information about children and adolescents are then discussed.
These two chapters successfully communicate the complex loyalties invoked by
dealing with children and families, and the vulnerability of the patient group.
Following this, four
different perspectives are offered, focussing on social work, nursing,
situations of dual responsibilities (eg prisons) and the challenges posed to
The two legal contributors
provide an interesting overview of contemporary case law, including cases from
the European Court of Human Rights. Their reasoned commentaries are succinct
and thought provoking.
In the penultimate
chapter, the research implications and their regulation are addressed
comprehensively. The book finishes with a discussion of the group processes
during the conference, drawing parallels between the vexed issues raised by
confidentiality, and their exploration by groups of psychiatrists. There is an
appendix containing the General Medical Council guidelines on confidentiality.
This is, overall, an
excellent collection. The contributors have a wide range of experiences, and
succeed in developing arguments rather than merely pointing out the issues.
Some positions are quite polemic! The volume is reasonably consistent, although
some of the middle chapters are weaker than the initial chapters and legal
This book will date,
but in the meantime it provides an invaluable resource for understanding the
pressures on mental health professionals in an increasingly complex terrain.
Dealing simultaneously with increasingly paternalistic laws providing for
detention, and with the expectation of partnership with service users, is
highly challenging. This book doesnt set out to provide answers, but explores
the nature of the tension between confidentiality and breach. It should be
mandatory reading for mental health professionals in the UK, and the
contributors have solid ideas to offer to an international audience.
© 2002 Danny Sullivan
Confidentiality and Mental Health is also
available from Amazon.co.uk.
Danny Sullivan graduated in
medicine in Australia in 1994. He has since completed a Masters Degree in
Bioethics and a Masters Degree in Medical Law. He is training in psychiatry at
the Maudsley Hospital and Institute of
Psychiatry in London, UK, and remains an Honorary Research
Associate of Monash University.