Just Between Us

An interesting comment was made in my practicum yesterday, which brought to mind the subject of confidentiality. As part of the support group I facilitate for the Addictions Foundation of Manitoba, I attend a weekly exercise class with a small group of seniors. Yesterday, one group member commented that she had been asked by someone else at the gym what kind of group we were, with one young woman doing exercises with a group of seniors. She had to do some quick thinking to avoid revealing that we were an addictions support group, which would have violated the confidentiality of the group members.
In my practicum, as well, as in all our social work education, the importance of confidentiality is always a major theme. Of course, this value is not specific to social work alone, but is a major consideration in the medical and legal professions, among others. Wynia (2007) suggests several reasons for the high priority we place on confidentiality; in the first place, it reflects our commitment to privacy, and in the second, it provides safe ground for clients to open up and frankly share information with care providers and professionals. Wynia also points out that like other ethical principles, confidentiality is not necessarily an absolute. I found this to be a very interesting argument, and wanted to consider how it could be integrated into our future role as social workers and some of the decisions we may have to make one day.
Actually, this topic really became interesting to me during a discussion with some friends about the duty to report child pornography when this recently became law. This led me to look up the relevant laws in Manitoba, which in this case are found in The Child and Family Services Act. The law makes it clear that anyone who suspects that a child is being abused has a duty to report that information to the relevant authorities. This law applies regardless of confidentiality from professional relationships, except that the lawyer-client relationship is exempt.
Although I definitely agree with this law in principle, it raises two significant problems for me. First, maybe I am interpreting this incorrectly, but if the law formalizes the opinion that child abuse is so terrible that reporting it is more important the doctor-patient or social worker-client confidentiality, then why is the lawyer-client relationship given a special status. The cynic in me wants to argue that perhaps this is because lawyers, but not doctors or social workers, write the laws.
Aside from this, the bigger question for me is about how the line is drawn when it comes to mandatory reporting - that is, violating confidentiality. To me, the basic principle behind this law is that children are such a vulnerable and defenseless group that the government considers their protection to be of the highest priority - so high that it outweighs many of the traditional confidentiality guarantees that people are owed by caregivers. In my practicum, I work with many elderly women who are incredibly vulnerable and in many ways are equally as helpless as children - or even more so. Their physical and emotional strength is sometimes almost non-existent, their cognition is in some cases regressing to a child-like level, and many have little or no financial resources. In short, they could scarcely be more vulnerable to abuse. Even worse, their increasing fragility means that unlike children who parents often find "seem to be made of rubber", senior women may suffer even greater consequences from physical abuse than do children who nature has designed to rebound from the inevitable bumps and blows of tripping on the playground or falling off of the tire swing.
Considering the above, then, if the law is resolved to overrule the principle of confidentiality (except for lawyers) with respect to children, why does it not do so for another intensely vulnerable group in society?
Of course, the pragmatic answer is that confidentiality cannot be lightly dismissed without incurring unintended consequences. As Wynia suggests, no ethical principle is absolute, and confidentiality serves a practical purpose as well as an ethical one. If seniors knew that any mention of elder abuse would mean a mandatory report on the part of their social workers, they are very likely to begin hiding information from their caregivers. Nevertheless, this argument can then be extended to children to point out that many children today are well aware of the dangerous power of the threat "if you hit me, I'll tell my teachers and they'll take us away from you!" The other side of that coin is that many children may fear to tell their teachers, doctors, social workers and so forth about abuse for fear that it may destroy their family. Whether or not this perception is correct is irrelevant, since only an element of doubt in confidentiality is needed to destroy the trust in the relationship.
Ultimately, there are no easy answers to this dilemma, but I really believe that as social workers who advocate and influence policy decisions, this is a very important question for each of us to carefully consider for ourselves.

References

Province of Manitoba. (2010). The Child and Family Services Act. Retrieved from http://web2.gov.mb.ca/laws/statutes/ccsm/c080e.php?ccsm=c80

Wynia, M. K. (2007). Breaching confidentiality to protect the public: evolving standards of medical confidentiality for military detainees. The American Journal of Bioethics, 7(8), 1-5.