Case Study

Confidentiality and Air Force One

Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the

second in a series of case studies for the IHI Open School.

Physicians at Andrews Air Force Base in Maryland pulled MOD (medical officer of the day)

about once a month. It was a 24-hour shift. During the day, instead of seeing his or her own

scheduled patients, the MOD cared for walk-ins. Then, from 5 PM to 8 AM the next morning,

the MOD saw all adult patients in the emergency room.

One morning near the end of my MOD shift, a senior non-commissioned officer presented with

complaints of abdominal pain. He was the crew chief for Air Force One, the plane that carried

the President of the United States. As I prepared to examine the patient, I detected alcohol on his

breath. The abdominal examination showed that he had an enlarged, slightly tender liver. He also

had a few “spiders” on his face and upper chest, red lines radiating out a few millimeters from a

small red dot.

I told the patient that his abdominal pain was due to an enlarged liver. I commented about the

odor of alcohol on his breath. I indicated that the two were almost certainly connected and that

continued drinking would be a risk to his life. I suggested that he seek help through Alcoholics

Anonymous. He immediately denied the problem and would entertain no further discussion of

the issue.

The patient was not sufficiently ill to warrant removing him from flying status on medical

grounds. Yet, he was in a position that called for alertness and good judgment.

I was faced with a difficult choice.

Physicians are expected to maintain the confidentiality of their patient findings; if I shared my

findings with his superior, I would be breaching that confidentiality.

Discussion Questions:

1. Would you attempt to continue the conversation with the patient? Why or why not? 2. How would you handle this situation? Would you inform the pilot’s superior? Would

discussing the problem with his wife be a first consideration?

3. What if the patient had been a commercial airline pilot? Would you contact the pilot’s employer?

4. What right do patients have to confidentiality with their caregivers? 5. Can you think of any situations where you would breach a patient’s confidentiality? 6. Think back to your own experiences. Have you had a similar experience with patient

confidentiality? What was the result?

Commentary from Dr. Griner:

After much thought, I elected to inform the patient’s commander of my findings and offered

suggestions for treatment. My reasons for breaching confidentiality were two-fold:

 First, I considered him a risk to the safety of the President and anyone else aboard Air Force One.

 Second, I expected that by informing his superior, the patient would be forced to either address his alcoholism or face removal from the service.

The patient was immediately removed from flight status and offered the option of treatment for

alcoholism or discharge from the Air Force. He opted for treatment. I never knew whether he

succeeded in becoming sober.

Leonard Fleck, trained in moral philosophy, suggests that the only circumstance where

confidentiality may be breached is when there is an (a) imminent threat of serious and

irreversible harm, (b) no alternative to averting that threat other than this breach of

confidentiality, and (c) proportionality between the harm averted by this breach of

confidentiality and the harm associated with such a breach.

Reference: Fleck, L. (1991). Please don’t tell. Hastings Center Report, 21, 39-40.