Ethical issues

Some similarities were noted across the three contexts regarding concerns with sensitive information and how to handle these concerns during report writing. The participants from the public context spoke specifically around managing information such as reporting on the HIV (Human Immunodeficiency Virus) status of a patient. This is a daily reality for therapists in South Africa with the HIV prevalence rate being approximately 6 700 000 - 7 400 000 people living with HIV [UNAIDS, 2015].

The concern raised by the participants in the public sector was mainly around divulging this information to a non-medical professional such as the employer or a member of the work place or the client themselves. The current approach by participants within this context appeared to be to omit this information, rather than specifically understanding the legal and ethical policies that govern this.

Amongst the independent private practitioners there was also some consensus that practitioners have the right to withhold certain information. The withholding of information, however, brought up a moral conflict and was contested by a participant who had first-hand experience of being involved in a situation where information had not been given. She felt that this practice

104 affects the autonomy of the patient and the family. This professional practice guideline is supported by OTASA code of ethics, which states: -

“The practitioner should not withhold any information or mislead the client in any matter that would limit his or her autonomy. Such information should be provided in a form and language which makes it possible for the information to be useful and understood without causing undue harm or engendering feelings of helplessness” p2[Occupational Therapy Association of South Africa, 2005]

The participants could not come up with a different solution. Legislation such as the Protection of Personal Information Act (POPI) [South African Government, 2013] and other government policies have been established to guarantee minimum requirements for the management of personal information, and to ensure that the rights of persons regarding their personal information are not violated. Practitioners should adhere to this legislation. Amongst others, the legislation and policies entrenches an individual’s right to give consent before their information is disseminated [South African Government, 2013]. The right to consent to disclosure is echoed in the HPCSA booklet 14, Guidance on the keeping of patient records [Health Professions Council of South Africa, 2008b]. Guidance around confidentiality is also included in the OTASA code of ethics, which states that for reports to be submitted to other parties, all information should be kept confidential unless consent is given by the client [Occupational Therapy Association of South Africa, 2005]. If the confidentiality of the report is considered then the patient must give consent for their report to be disseminated. Consideration around the ownership of the report is therefore needed. Does the fact that the corporate and funding bodies, such as medical aids, are paying for the therapy give them the right to dictate what to include in occupational therapy assessments and reports?

Participants from the private context in particular voiced ethical concerns around the billing of report writing. Therapists feel the corporate and funding bodies are making report writing more expensive than necessary by setting

105 demands in relation to what must be reported so that services are paid for. The ethical repercussions of the commodification of healthcare and rehabilitation practices are complex. If the emphasis of health and rehabilitation intervention is on making profit, this may result in the replacement of professional ethics with business ethics [Rowe and Moodley, 2013]. The report may then be seen as a product, which is owned, rather than a reflection of the patients care pathway. To note however, there is no agreement on the ownership of records internationally with Terry (2015) indicating “while patients have a legal right to their medical records” if they ask for them, the professional is the caretaker of the records and should control access to the records [Terry, 2015]. Thus there appears to be no best practice in who owns patient records, who should have access to a patients records and for whom they should be written.

Even though participants could name these policies and legal guidelines such as the POPI act and HPCSA guidelines, they admitted that they did not know the specifics and could not be sure how these impacted on the reports. Therefore, it appears that therapists either have not read or accessed or understood these guidelines and therefore cannot apply best practice according to these guidelines when considering confidentiality issues in writing occupational therapy reports. These findings have been supported by other research on report writing in South Africa [Buchanan et al., 2016; Rischmuller and Franzsen, 2012; van Biljon et al., 2015]. A concern addressed in these prior studies is the possibility that reports can be used for legal purposes, where a therapist can unwittingly become involved in litigation, if they do not understand the legislation around confidentiality and implement this in their reports. It would be in therapists’ best interests to be members of professional bodies and special interest groups, where they can seek guidance and support in the legislation around report writing and dissemination of information. Interestingly, the participants from the academic context understood this issue as an overview to maintaining confidentiality. It was identified that if practitioners simply wrote what is pertinent just to occupation, they may then avoid these issues around confidentiality. One

106 could argue theirs may be a theoretical but narrow view that seldom matches the clinical context, specifically when referrers require specific information and the effect of context and personal history on occupation [Cross, 2001].

A group of participants in the public sector voiced ethical concerns related to the patients’ rights and their ability to take responsibility for dealing with their records and act on recommendations made by practitioners in these reports. Their concern supported the role that professionals play in ensuring maintenance and dissemination of records while maintaining client centeredness during intervention, as is stipulated by governing bodies such as the HPCSA –

“Health care practitioners should honour the right of patients to self- determination or to make their own informed choices, and to live their lives by their own beliefs, values and preferences” p7[Health Professions Council of South Africa, 2008a]

Professional bodies such as OTASA [Occupational Therapy Association of South Africa, 2005] support this view but participants felt that clients often appeared apathetic in taking responsibility for understanding the implications of the reports and the affect on their healthcare. Participants felt clients were also indifferent in terms of implementing recommendations made in reports and therefore felt that by providing patients with written reports often did not achieve any outcome. The indifference or apathy to involvement in patient’s’ own care could be related to aspects of poor health literacy where poor understanding alienates health care users from access and effectively partaking in the health care process [Kickbusch, 2001; Nutbeam, 2008].