Confidentiality In A Teen Age Unmarried Pregnant Indian Girl

Confidentiality in Indian Medical Ethics

Confidentiality is a patient’s fundamental right. Disclosure—by design or default—to a third party that may harm the patient is a punishable offence. Preventing disclosure by default in Indian hospital settings is a dilemma.

Case Introduction

Question: I would like to discuss a case of an unmarried teenage pregnant Indian girl. The social norms of traditional Indian society are very different from those in permissive Western societies. The discussion should strictly address norms and sensitivities of Indian society, including religious considerations.

A Case of an Unmarried Pregnant Girl

A 17-year-old unmarried girl is brought to the hospital emergency department with abdominal pain and vomiting. She had fainted at home, and her parents brought her in after she regained consciousness.

On examination, she is very pale. Her pulse rate is high, respiration increased, and blood pressure low. Her menstrual history is unclear. The surgeon suspects internal bleeding and advises immediate admission and surgery.

During the operation, a ruptured ectopic pregnancy is discovered. The surgeon removes the affected fallopian tube and the conceptus, thereby saving her life.

Ethical Questions

1. Confidentiality – Should the finding be disclosed to the parents?
2. Truthfulness – Should the finding be recorded truthfully in the operation and patient records?
3. Clinical Ethics – Should the removed tissues be sent for histopathological examination with the patient’s identity?

Discussion of Ethical Questions in Traditional Indian Context

1. Confidentiality: Disclosing Findings to the Parents

• Parents’ Right to Know: Under Indian law, a minor’s treatment requires parental consent. Failing to inform the parents of a life-threatening condition could result in legal implications.
• Protecting Family Honor: The surgeon may explain the urgency of surgery without publicly revealing the term “ectopic pregnancy.” Disclosure should be done privately and respectfully, ideally with only the mother and father present.
• Balancing Stigma and Support: Focus on the medical urgency and survival, avoiding moral judgments.

2. Truthfulness: Recording the Operation and Patient Notes

• Medical Integrity: Indian Medical Council guidelines mandate truthful and complete clinical records. Omitting the diagnosis could result in charges of professional misconduct.
• Legal Safeguard: Accurate records protect the physician if questions arise from legal or administrative authorities.
• Religious Sensitivity: Major religions in India value truthfulness. The notes can be stored in secure hospital records to restrict access.

3. Clinical Ethics: Sending Removed Tissues for Histopathology

• Medical Necessity: Histopathology confirms the diagnosis and ensures quality control. Indian law mandates submission for medico-legal accuracy.
• Patient Identity and Anonymity: Use a unique hospital ID instead of a full name. The report can reference this code to protect identity.

Key Recommendations and Practical Steps

• Family Communication: Arrange a private meeting with the parents. Focus on medical facts and fertility implications.
• Record Keeping: Document “ruptured ectopic pregnancy” and “salpingectomy” in operative and discharge notes. Secure all records appropriately.
• Histopathology: Use a hospital code instead of the full name when labeling specimens.

By combining truthful documentation with sensitive family engagement, the surgeon can meet both professional obligations and traditional expectations.

Surgeon’s Actions

1. He informs the girl’s parents about the ectopic pregnancy. They deny the possibility.
2. He sends the specimen for histopathological examination using the patient’s IPD number, but only initials for the name.
3. He personally collects the report and avoids placing it in the standard patient file.
4. He truthfully enters the operation notes but removes the sheet from the ward file and keeps it separately.

Further Questions

1. Should the pregnancy be mentioned in the discharge summary?
2. Should all records, including operative notes and histopathology reports, be stored in the IPD record room?

Ethical Principles: Confidentiality and Truthfulness

1. Discharge Summary

The discharge summary should explicitly mention the ectopic pregnancy and the salpingectomy. Omitting this would breach medical ethics and compromise future care. As the patient already knows her diagnosis, this inclusion supports proper follow-up and counseling.

2. Archiving in the IPD Record Room

All medical documents—including operative and histopathology reports—must be included in the IPD file. Completeness ensures clinical continuity and legal protection. Confidentiality can be preserved using role-based access and coded identifiers.

Further Considerations

• Offer post-discharge counseling on reproductive health and social support.
• Ensure up-to-date hospital policy on minor consent and access to records.
• Explore options for coded or sealed notes to prepare for potential legal issues.

By balancing transparency in documentation with confidentiality protections, the surgeon fulfills both professional and cultural duties in caring for an unmarried teenage patient.

Q. Surgeon’s Action

1. He prepares the discharge summary, truthfully mentioning the ectopic pregnancy and its histopathological confirmation, and keeps a carbon copy of it as is the routine. However, he gives the discharge ticket to the patient and tells her what is written in it. He also tells her that in case the discharge ticket is lost or gets destroyed for any reason, the record can be retrieved if she tells the hospital about her OPD and IPD number.
2. He withdraws all relevant records from the IPD folder and leaves a signed paper stating that the record is in the personal custody of the surgeon.

Further Action

Three years later, the same girl, now married (sindoor et al), enters the surgeon’s chamber with her husband. The husband has withdrawn the record from the hospital OPD, which has the surgeon’s note about the record being in his personal custody. The husband wants to see and have the record, and wants to know what his wife had been treated for.

Ethics – Confidentiality and Truthfulness

What should the surgeon do? What will you do in his position?

What is the legal position? Is the surgeon obliged to give the record?

Scenario Recap

Three years after treating a 17-year-old’s ruptured ectopic pregnancy, the now-adult patient (married) and her husband request the hospital record. The hospital folder no longer contains the operative notes or histopathology report—they’re in the surgeon’s personal custody per his signed note.

Ethical Duties

Confidentiality

• Medical confidentiality is a core fiduciary duty under the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.
• Patient data—including diagnoses and operative details—belongs solely to the patient. Even a spouse isn’t automatically entitled to these details without the patient’s consent.

Truthfulness

• Honesty in documentation is non-negotiable: charts, discharge summaries, and histopathology reports must accurately reflect the patient’s care.
• Withholding or sanitizing records from the official hospital file breaches professional integrity and undermines continuity of care.

Legal Framework in India

Record Retention and Patient Access

• MCI Regulations mandate that hospitals maintain in-patient records for at least three years and furnish copies to patients (or their authorized agents) within 72 hours of request.
• The Consumer Protection Act and Limitation Act allow medico-legal complaints to be filed years after treatment, making record retention crucial.

Third-Party Access

• Under Indian law, only the patient or a person legally authorized by the patient (e.g., via power of attorney) can demand medical records.
• A spouse has no standalone right to inspect or obtain records absent explicit patient consent or a court order compelling disclosure.

Court or Police Orders

• Records may be disclosed if a court summons or a police requisition is issued under due process. Otherwise, disclosure to third parties risks professional misconduct charges.

Recommended Action for the Surgeon

1. Respect Confidentiality
   • Decline the husband’s direct request for records, citing patient confidentiality obligations.
   • Explain that only the patient can authorize release or a court order can compel it.
2. Encourage Patient-Led Access
   • Invite the wife to request her records in writing.
   • Once she signs consent, provide certified copies of all relevant documents without alteration.
3. Restore Institutional Records
   • Return all withdrawn notes, histopathology reports, and summaries to the hospital’s IPD file.
   • Personal custody of official records is impermissible under MCI norms and risks disciplinary action.
4. Document the Interaction
   • Make a contemporaneous note in the hospital file of the husband’s request, the refusal, and the patient-consent pathway offered.

Personal Stance

If I were the surgeon, I would firmly—but compassionately—refuse the husband’s demand, uphold the patient’s confidentiality, and guide both to the proper legal channel: the patient’s written consent or a court order. This balances my ethical duty to truth and confidentiality with legal compliance and respect for the patient’s autonomy.

Q. Real-Life Scenario: Ethical vs Practical Realities

This, strictly legal stance is what it should be. But the surgeon in this case thought otherwise. In the real-time Indian scenario, he felt that this would raise the husband’s suspicion. He has seen the scar on his wife’s abdomen. He is concerned about her persisting gynecological problems and wants to consult a gynecologist for the same. It is for this that he needs the information. His suspicion raised would do the damage—and all that he did to protect the girl would come to a naught. The situation demanded more ingenuity to navigate. Any suggestions?

Navigating Confidentiality and Compassion in Practice

When the husband’s concerns stem from genuine worry about his wife’s health, a rigid refusal can backfire. Here’s a multi-pronged strategy that preserves her confidentiality, addresses his fears, and keeps her safe:

1. Private, Empowering Dialogue with the Patient

• Invite her for a one-on-one chat in a calm setting.
• Explain her right to confidentiality and the risks of premature disclosure (misunderstanding, marital conflict).
• Explore what, if anything, she’s comfortable having her husband know—perhaps a brief summary she approves, rather than full records.
• If she fears domestic repercussions, involve a trained counselor or social worker immediately.

2. Offer Generalized Medical Guidance to the Husband

• Without revealing specifics, acknowledge his worry and advise him on common post-op gynecological follow-ups (e.g., periodic ultrasounds, lab tests).
• Provide a generic referral letter to a gynecologist confirming only that “Mrs. X underwent abdominal surgery; specialist evaluation is recommended.”

The last ‘offer’ is almost what the surgeon did. But in his own way—taking both of them in confidence, giving them suitably worded personal referral to the gynecologist, and talking to the gynecologist per their request.

Written By: Dr Shri Gopal Kabra
MBBS, LLB, MSc, MS(Anatomy). MS(Surgery)
Email: [email protected], Ph no: 8003516198