Exceptions to Professional Secrecy

Public Health Protection and the Diseases that must be Reported

Under review

CLINICAL CASE 
You meet Mr. Simon L., who asks you for a screening test for HIV because he fears having been contaminated by a transfusion. But he hesitates to undergo the testing because he doesn’t trust the results to remain confidential.
What do you do?

The Public Health Act provides for means to better identify and control threats to public health. Thus, it recognizes the obligation of physicians and laboratories to report to the director of public health in their territory the infections, diseases and intoxications for which surveillance is required, in accordance with the Minister’s Regulation. It also establishes, as necessary, the interventions required to protect the public, in. this case, the diseases for which reporting is mandatory  (maladies à déclaration obligatoire—MADO).

The legislation does not violate professional  secrecy; indeed it takes it into account and reinforces it, in as much as the public health director to whom the diseases and intoxications are reported must be a physician, who is bound by the same obligations as are all physicians in the performance of their functions.

Every physician has a responsibility with respect to public health, if he or she judges that a patient’s illness is likely to threaten those who come into contact with that patient. This responsibility is spelled out in the Code of Ethics of Physicians (sec. 40):

“A physician who has reason to believe that the health of the population or of a group of individuals is threatened must notify the appropriate public health authorities.”

The public health authority referred to in this section falls to the public health director in the region.

The Minister’s Regulation respecting the application of the Public Health Act lists the diseases that must be reported (MADO) and the ways and means of reporting them. This list, which is regularly updated, is presented in the Appendix; it distinguishes three groups:

  • High-alert diseases that must be reported (anthrax, botulism, cholera, plague, smallpox, viral hemorrhagic fever, yellow fever). These must be reported
    immediately, by telephone or by fax, simultaneously to the national public health director and to the public health director in the territory and confirmed in writing within 48 hours.
  • Diseases of infectious origin. These must be reported in writing to the public health director in the territory by means of a form used expressly for this purpose (AS-770) (Appendix B) and available from the director of public health in the territory. This list includes some 50 infections.
  • Diseases of non-infectious origin (intoxications). These must be reported in a manner similar to that of diseases of infectious origin.

Once the disease is reported, the director of public health may use the powers provided for in the legislation to investigate and intervene so as to protect the health of the population.

But the physician’s obligation to report is not limited to the diseases listed in the Regulation. In fact, sections 93 and 95 of the  Act  include provisions aimed at extending the responsibility to report, with a view to adding any new, heretofore unknown, syndrome, as was the case when AIDS was identified in 1982 or SARS in 2003. Thus sections 93 and 95 cite the following:

“Any physician who suspects a threat to  the health of the population must notify the appropriate public health director.” (sec.93)

"Reporting a situation under this chapter does not authorize the person making the report to disclose personal or confidential information unless, after evaluating the situation, the public health authority concerned requires such information in the exercise of the powers provided for in Chapter XI.” (sec. 95)

The “public health authority” mentioned in section 95 is the director of public health, and the “powers provided for in Chapter XI” are the powers of investigation entrusted to him. These are similar to the powers of a commissioner in a commission of inquiry.

The physician-director of public health must exercise his or her powers and mandate, while respecting the ethical obligations of all physicians, among them, professional secrecy, and legal obligations, notably all legislative provisions protecting privacy and personal information. Thus, the physician’s disclosure of information to a colleague who is a physician-director of public health amounts to the sharing of a professional secret, similar to the sharing of patient information between an attending physician and the medical colleagues he or she consults.

In the spirit of the Public Health Act, responsibility for vigilance in the face of threats to public health is to be shared by all physicians.

As for this case in particular, it  should be kept in mind that the human immunodeficiency virus (AIDS) is a disease that must be reported when blood, blood products, tissues or organs are donated or received. In this case, the physician must complete the AS-770 form. Note also that, to encourage screening for sexually transmitted and blood-borne diseases in vulnerable populations, there are integrated services providing screening on an anonymous basis.

You explain to Mr. Simon L. that you must transmit to the public health authorities information that will identify him if the test  is positive. You urge him to have the test nonetheless, since the public health authorities are obliged to protect the confidentiality of the information. 

2011-04-04