Confidentiality and cognitive impairment: professional and philosophical ethics

In the UK, the General Medical Council's new guidance on confidentiality restates the professional duty for doctors to regard personal information revealed to them as confidential. Such information can be shared only with the patient's explicit consent--the exceptions to this are narrowly defined. We believe the guidance does not adequately address the reality of confidentiality in modern practice, particularly in relation to patients with dementia. It seems to be naïve or lacking in the subtlety required in complex clinical situations, perhaps because its legalistic, professional ethics have a philosophically limited view of confidentiality. A more sophisticated philosophical picture regards people as embedded in a shared, worldly context, in which relationships and mutual engagement become crucial. Attending to the reality of cognitively impaired people emphasizes this context and suggests that confidentiality cannot be an overriding principle--it is best regarded as a token of trust.