Chaplains and Confidentiality

Robert, a board-certified hospital chaplain assigned to the cancer center of a large community hospital in the Midwest, receives a handwritten note from Jennifer, the daughter of a patient, Gloria, who died two years earlier. Jennifer's parents were divorced when she was in her teens. She subsequently lived with her father on the East Coast, where she continued to live as an adult. She is now in her midtwenties. According to her note, bitter "family dynamics" had prevented Jennifer from being with Gloria when she was dying. Jennifer writes that one of her siblings told her about their mother mentioning "wonderful visits" with Robert during her hospitalizations. She asks Robert if it would be possible to talk with him about Gloria's last days. As she writes, "I would love to know something about this time in her life."

Robert is uncertain about what to do. On the one hand, as a hospital employee, he is bound by HIPAA, which protects the privacy of health information, and by the hospital's own confidentiality policy, which allows patients to designate which individuals may—or may not—be given information about their health. However, this patient is dead. And this patient's daughter is not requesting health information. Robert believes Jennifer is attempting to come to terms with her mother's death and with her own feelings about her mother. Having cared for many patients near the end of life, he is accustomed to caring for the family, too.

Robert remembers Gloria and her family well. He cannot recall her ever stating that she wanted their one-on-one conversations to be kept private. Nor were these conversations privileged as religious confessions: Gloria and Robert are of different faiths. But don't patients have the expectation of privacy when a chaplain invites them to talk about their deepest concerns?

• Commentary
• Martin L. Smith (bio)

Until Robert learns about any facts to the contrary, he should presume that Jennifer has emotional and spiritual needs related to her mother's dying and death, and that he should reach out to her in her time of need as he would do with other family members of dying and deceased patients. In other words, Jennifer needs pastoral-spiritual care related to her grieving process, and Robert is in a unique position to respond, given his significant role during Gloria's hospitalizations for her cancer care. This creates for him a strong ethical obligation to respond in some way to Jennifer's request.

A central issue for Robert is what limitations to place on disclosing to Jennifer the content of his conversations with Gloria. An argument could be made that because Gloria is deceased, she no longer has the same rights and protections as a living patient. Nevertheless, because there do not appear to be any countervailing and significant values that could only be upheld by breaching her confidentiality, Robert should be careful about what he communicates to Jennifer. Although he may not have formally functioned as Gloria's "confessor" and he does not recall her explicitly stating that she wished their conversations to remain confidential, he should not interpret these facts to mean that Gloria would have wanted him to tell her family every detail of their visits together.

Since Gloria did not direct what Robert could disclose to her family, he should use a "reasonable person" standard for deciding what he should disclose to them. For example, Gloria might have talked to Robert about deep-seated jealousies, anger, or hatreds, sexual indiscretions or chemical dependency problems, or lies and deceits that had become woven into the fabric of her life. She might have received his counsel and advice on these matters without necessarily viewing him as a minister of divine absolution. Most people under ordinary circumstances would not want such aspects of their lives disclosed to even close family members without their explicit consent.

From his visits with Gloria, Robert may already have insights about her relationships with her family members, including Jennifer. How Gloria viewed her relationship with Jennifer both before and after Jennifer moved away may provide a context for Robert's discernment about how best to respond...