Confidential Information Case Study (Harvard Citation)

Confidential information generally consists of non-public information about people or institutions that if it were to be disclosed, could be expected to place either the person or the institution at risk. These risks could be criminal in nature, but also could be civil liability, financial standing, employability, reputation or privacy. ("601" 2010) In most businesses, employees are strictly regulated as to what information can be disclosed about other employees. However, in many businesses, people are routinely exposed to confidential information that could possibly cause harm and must weigh the various ethical concerns involved. These include the problems involved over their agreeing not to disclose such information when they were hired, as well as the possible harm disclosing the information could cause to the company, or any of it's employees. But this must be weighed against the possible harm that not disclosing such information could pose to the company, it's clients, or the public at large.

While in the medical profession, there is a standing doctor-patient confidentiality agreement which restricts doctors from disclosing information about their patients, (Opinion 5.05) what happens when information about a doctor is disclosed? What is an employee to do when they have knowledge that a doctor is acting unethically? Disclosing such information could harm the health care company, the doctor's professional reputation, and even lead to the one who disclosed the information losing their job, and possibly face criminal charges and civil liability. But when a doctor is performing unethical actions, there is also the ethical concern over their duty to provide the patient with the best health care possible. In 2009, two employees of a hospital were faced with that exact ethical dilemma. ("Nurses Win" 2011)

Dr. Rolando Arafiles, Jr., M.D. worked part-time in the clinic of Winkler Memorial Hospital, a small 25-bed government-owned hospital in Kermit, Texas, a town of just 5,000 residents located 35 miles west of Odessa. Two long-time employees, R.N.'s Anne Mitchell and Vickilyn Galle became aware that Dr. Arafiles "was emailing patients he had seen to encourage them to buy herbal products that he sold." (Barrett 2011) Arafiles often sent patients home with a sample of a "dietary supplement," and then would follow up with an offer to purchase the "supplement" from Arafiles (Elbein 2011) The nurses noticed that Dr. Arafiles also began to change medicines on patients who had been on thyroid meds for years and were stable, but failed to check up on the patients to see if the new meds were working. When one of the nurses confronted Arafiles about his treatments, the doctor attempted to get the nurse to follow his example. He wanted her to prescribe thyroid medications based on, as the doctor told her, "obesity, extra fat behind the arm, fatigue, and that's all you need to know." (Elbein 2011) When she asked for further literature on the subject to confirm his treatments, he brought her two paperback books on alternative medicine.

But his seemingly bizarre medical knowledge was not his only failings, Dr. Arafiles also performed surgeries at the hospital, when it was not set up for surgical procedures. Arafiles was not even certified as a surgeon, something that was proven when he sewed part of a glove onto a patient's hand. The doctor also hammered a needle into a woman's broken bone in order to stabilize it. But the most egregious case of his incompetence as a surgeon came when he attempted to perform a skin graft on a 73-year-old diabetic patient by cutting a strip of skin off the man's abdomen and grafted it to his hand. It failed miserably.

"Promoting and selling medical or non-medical products to patients for a profit is not only unethical, it constitutes a direct conflict of interest." (Thomas, 2010) And the two nurses recognized that Dr. Arafiles was in violation of this basic ethical principle. According to David Fleming, a medical ethics expert at the University of Missouri Medical School, "Doctors should not be in the retail business." (Howland, 1999) However, an attempt to introduce into American Medical Association guidelines a regulation that would deny doctors the right to sell products was met with fierce opposition, especially from dermatologists, plastic surgeons, and ophthalmologists. These particular specialists said they require the freedom to recommend certain products for their patient's healthcare needs. As a result, the AMA has no official policy restricting doctors from selling products and falling into the ethical trap of personally profiting from their patient's medical needs.

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In fact, more than three quarters of doctors surveyed admitted that they sell supplements in their office. (Thomas, 2010) However, while he may have been within his rights if he recommended the supplements in his own office, he was not within his rights to recommend such treatments as part of his position in the hospital. Not to mention that if the ultimate purpose of recommending supplements was to gain financially, and not to benefit the patient, then Dr. Arafiles was clearly in violation of ethical standards.
At this point the two nurses were becoming seriously concerned about Dr. Arafiles' actions, he was threatening the lives of the patients, but also threatening the health care facility's reputation and even existence. However, since they were bound by certain obligations to the facility, they decided to take their concerns to the hospital administrator, Stan Wiley. The nurses first went to the administrator in September of 2008, and told him of the doctor's strange behavior and said that they did not want him to get in trouble, just to follow the rules of the hospital. The nurses "assumed that Wiley, with his interest in keeping the hospital from being sued, would feel the same way." (Elbein 2011) However, the hospital administrator seemed oblivious to their concerns. His main concern was for the economic viability of the hospital, and Dr. Arafiles was bringing more patients into the hospital and thus making more money. Mr. Wiley wanted to ensure that the hospital was profitable, something that was necessary if it was to continue providing services for the people. Having one of their doctors reprimanded for unethical behavior would be an embarrassment for hospital. Wiley had an obligation to protect the hospital, not address the concerns of two nurses. But Mr. Wiley failed to realize that Dr. Arafiles was the one who was actually threatening the hospital's reputation by providing substandard service. Mr. Wiley put his obligation to the hospital and it's profitability over the obligation to provide the best health care possible.

Hospital policies were clear and the two nurses decided to write a letter to the doctor reminding him that "medications used by physicians and allied health care must have been approved by the regulatory agency i.e. FDA, and have the necessary documentation indicating dose benefits, possible adverse effects, drug interactions, etc." (Elbein 2011) But when Arafiles ignored them, they went to the hospital board and tried to inform them of the doctor's unethical actions. However, in the middle of their presentation to the board, Mr. Wiley interrupted them, argued in favor of Arafiles, and the board then tabled the complaints until they could obtain more information. They never brought the subject up again, except to forbid hospital employees from reporting about doctors without Wiley's permission. But the Bureau of Nurses Examiners requires that nurses take action when patients are being endangered. These two women were now in an ethical bind between their obligations to the hospital and its regulations, and their ethical obligations to the patients and their care. Fearing that the patients, and even the hospital, were being endangered by the unethical actions of Dr. Arafiles, Mr. Wiley, and the hospital board, the nurses decided to act outside the institutional procedures. The two nurses wrote an anonymous letter to the licensing board detailing several of Arafiles' ethical violations and professional incompetence.

"When Arafiles was informed of the complaint, he protested to his friend, the Winkler County sheriff." (Sack 2010, "Hearing" 2010) The sheriff investigated Arafiles' claims that he was being harassed, obtained a search warrant for the two nurses' homes, and found a copy of the letter on one of their personal computers. The two nurses were then arrested and charged with "misuse of official information, a third-degree felony in Texas" (Sack 2010) They were fired from their jobs and had to defend themselves in court, but ultimately were acquitted of all charges. Because the nurses had an obligation to report the information, the hospital was later fined by the Department of Social and Health Services for "discrimination relating to employee reporting a violation of law." (Winkler County Nurses) They also won a lawsuit against the hospital, the doctor, the administrator, several board members, as well as the sheriff, and prosecutor for violating their "constitutional right to free speech, and due process" and because the "nurses had done what the law allowed- report issues of patient safety…