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Patient confidentiality and autonomy: how do we account for coercive control?
  1. C E Cohen1,
  2. R J Caswell2,3
  3. on behalf of the BASHH Sexual Violence Special Interest Group
  1. 1Department of HIV and GUM, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  2. 2Department of Sexual Health and HIV Medicine, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
  3. 3British Association for Sexual Health and HIV (BASHH)
  1. Correspondence to Dr RJ Caswell, Department of Sexual Health and HIV Medicine, University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK; rachelcaswell{at}nhs.net

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October 2016 saw the launch of the BASHH Toolkit to assist routine enquiry on domestic abuse within sexual health.1 It is anticipated that many services nationally will have begun this process or may have reflected on the content of the toolkit to improve their enquiry and referral pathways.

We wish to draw clinician's attention to the new General Medical Council (GMC) guidance on confidentiality, which comes into effect on 25 April 2017.2 The guidance gives due consideration to issues of patient confidentiality and autonomy, however, we believe further understanding and consideration of coercive control is needed.

We remind clinicians that the foundations of good medical practise include making the care of your patient your first concern; taking prompt action if you think that patient safety, dignity or comfort is being compromised; protecting and promoting the health of patients and the public and supporting patients in caring for themselves to improve and maintain their health and autonomy.3 In the context of domestic abuse, widely acknowledged as a major health issue, there remain several challenges for doctors when considering patient confidentiality and autonomy.

In the new GMC guidance, we welcome the emphasis placed on the appropriate sharing of information within the multidisciplinary and multiagency team and recognise this is vital for the care of domestic abuse survivors. Advice is given and patients are provided with information they need to make decisions in their own interests, for example, contacting specialist support agencies.

The new guidance also makes it clear in paragraph 57, that adults who have capacity are entitled to make decisions in their own interests, even if others consider those decisions to be irrational or unwise. In paragraph 59, it advises doctors to usually abide by a patient's refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm. We fully support this notion when it is clear that individuals are making those choices without duress.

Unfortunately, there is a real danger for the safety of lone adult survivors who disclose high-risk abuse with clear escalation or who present with high-risk indictors for homicide, but decline onward referral or information sharing. GMC guidance does not clearly support breaching confidentiality in such cases, as they do not meet the threshold for public interest, nor may weapons be a feature. However, a sound understanding of the coercive control legislation provides the context for meeting the risk level described as necessary to share under the prevention of crime act or in patient best interest when capacity is impaired by undue influence, particularly when there is an absence of physical violence.4

We urge clinicians to be aware of this new coercive control UK legislation within the field of domestic abuse.4 Professionals have a duty of care to ensure whether an unwise decision has been made freely and not unduly controlled or influenced by fear or threats.5 The new GMC guidance does not make reference to the latest legislation, despite the fact that Domestic Homicide Reviews repeatedly cite missed opportunities within health services for information sharing.6 ,7 Furthermore, as in other areas of safeguarding, a clinician cannot build a correct picture or make a correct risk assessment unless information is shared, and this has been a particular focus of child safeguarding practise changes.

Coercive control appears poorly understood and we remain concerned that doctors are left unable to fully assess its impact. We believe the new GMC guidance does not sufficiently consider the ethical approach to practising as a doctor to ensure a patient's autonomy. In making the care of patients our first concern, clinicians could be accused of paternalism and, if confidentiality is breached in high-risk cases, doctors could be accused of breaking their code of conduct. These are extremely complex issues and we would urge that further examination and discussion is held.

As a specialist interest group, we will be lobbying with other Royal Colleges and Specialist Domestic Abuse agencies on the proposed Domestic Violence Act consultation announced by Theresa May. We hope to raise awareness among doctors on the complexity of the GMC guidance when faced with lone adult survivors of domestic abuse and use it as a lever to secure better training across healthcare trusts, which is currently neither consistent nor across all specialties.

In advance of the new confidentiality guidance coming into effect, we advise that individual services link in with their local Caldicott guardians to pre-empt potential scenarios and have an agreed framework of working together to best support patient's privacy and confidentiality. This should ensure that the guidance does not prevent healthcare professionals from recognising and acknowledging an individual's continuing fear resulting from coercive control and the right of an individual to live free from threats and abuse.

References

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Footnotes

  • Collaborators The views expressed are those of the authors alone with support of the BASHH Sexual Violence Special Interest Group.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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