3.1. Ethical Issues Surrounding the Communication of Information

The ethical issues surrounding the communication of information in a clinical setting did not emerge suddenly at the same time as EHR. Confidentiality, professional secrecy, and all aspects of the disclosure or non-disclosure by caregivers of information gathered from patients as part of the professional relationship, are all mentioned in the Hippocratic Corpus (Beauchamp and Childress 2009, 303). However, the emergence of a clinical culture based on the ideal of interprofessional collaboration significantly changed the rules governing confidentiality. Since the 1980s, the strict interpretation of medical privilege has not been matched in actual practice, and the pressure placed by recent changes in clinical culture on the normative framework for confidentiality that applies to care professionals has a parallel in the field of chaplaincy.

The fundamental question for professional secrecy arises at the point of intersection between two key normative realities: the patient’s right to privacy and the needs of society, which include the need of the system and practitioners to ensure effective care delivery (Verdier 2007). This point is, in fact, a place of tension between professional secrecy and the “imperative” need of care professionals to share information (Gilbert and Mettler 2010; Pautier 2017; Gekière and Soudan 2015). At a time when interprofession collaboration within care teams is being consolidated, the sharing of private information is key to the efficient and effective coordination of care, provided the delicate balance between the rights and duties of all players in the care relationship is respected. Although the tension between privacy and public interest is well known and discussed in the fields of medical ethics and bioethics, it becomes even more acute when new technologies multiply the possibilities for accessing medical information and promote sharing between ever greater numbers of stakeholders.

The ethical issues surrounding communication can be encapsulated in a few key questions: What information should a chaplain enter in an EHR? What criterion or criteria should be used to sort all the information gathered? What justification should be required if a chaplain communicates a piece of information? What should be done with information that could compromise the patient’s insurability or influence the quality of the care relationship? To these questions we can add those concerning EHR access, which are addressed in Sect. 3.2.

For chaplains, the principle of charting is already accepted, since it is important to “leave footprints” (Ruff 1996), given that if it isn’t charted, it didn’t happen, according to the clinical adage. The “professional” imperative to document the spiritual support process arises as soon as the chaplain is required to “report” his or her actions to colleagues in the interdisciplinary care team. Although not needed to fulfil a reporting or accountability requirement, a note added to the file lets other clinical workers know what work the chaplain has done and what recommendations the chaplain has for the team.

An example will complete this examination of the ethical issues surrounding the communication of information using EHR: Ruff’s proposal, although dated, nevertheless presents the question of confidentiality effectively from the chaplain’s point of view (Ruff 1996, 389–390). Ruff uses principles such as the right to confidentiality and the right to privacy to establish a distinction between information collected under the confessional seal and information gathered during a “normal conversation” that is not sub secreto. The strict rules governing confession suffer no exceptions, while information from a conversation can be entered in the record unless the patient objects: “Chaplains must distinguish between information shared by a patient in the normal course of conversation and information shared under the confessional seal. The former, with appropriate pastoral sensitivity, can be charted. The latter should never be charted” (Ruff 1996, 389). If the chaplain has doubts, or if the patient has expressed reservations, the situation must be discussed and the chaplain must always respect the patient’s wishes. Ruff’s position is clearly in favour of sharing information with team members, but he specifies that “information can always be shared with other staff verbally if the chaplain feels it is appropriate or too sensitive to be included in the chart” (Ruff 1996, 390). The principles and rules presented by Ruff are still present in the latest versions of the codes of conduct for chaplains produced by professional associations such as the Association of Professional Chaplains (USA) and the Canadian Association for Spiritual Care and by associations that supervise training programs, such as the Association for Clinical Pastoral Education. All of these regulatory bodies expect that the “assessment and summary of a chaplain’s care is documented” (Common Standards for Professional Chaplaincy 2004). There is therefore a professional duty to add notes to the file, whatever its format – a duty created by the professionalization of the actions that provide spiritual support during illness. The Canadian Association for Spiritual Care (CASC) states, in its 2016 revised Code of Ethics , that the spiritual care practitioner “provide[s] other professionals with chart notes where they are used that further the treatment of the clients or patients, obtaining consent when required” and that s/he “communicate[s] sufficient information to other care team members while respecting the privacy of clients.”⁸

We can end this section by mentioning that the normative framework for the disclosure of information gathered by chaplains leaves room for professional judgment when determining what must be communicated, to whom, at what time, by what means and with what degree of consent from the patient. The relevant standards give chaplains a responsibility that, as it were, precedes the act of adding a note to the file. This is the responsibility to discern what can be disclosed and to obtain the patient’s consent to do so. In short, the responsibility is the same for any information entered in a file, whether paper-based or computerized.

3.2. Security of Computer System Access

This issue extends beyond the question of confidentiality between peers, to encompass institutional protection for the data gathered using the digital platforms made available to care teams. In addition to protection against piracy from outside the institution – obviously an issue that is not limited to healthcare institutions – institutions must guarantee that only authorized members of staff can access electronic files. Patients, of course, must have given consent to access (Manaouil 2009). But once these ethical and legal considerations are brought into play, a decision must be made concerning the extent of access. Who can consult the information in the EHR?

Three categories of “readers” other than care personnel come to mind, each with its own access context. The first category is clinical researchers, who may require access to the electronic files, just as they do to paper-based records. It has already been noted that EHRs are a significant source of research data, especially since consultation is facilitated by the digital format of the information stored. An anonymization process is needed before access to data and records is allowed. However, some jurisdictions prohibit the use of EHRs for epidemiological studies⁹ and limit access to purposes connected with the clinical coordination of care.

The second category is clinical training and covers interns in chaplaincy training programs. For these interns, training for their future profession necessarily relies on access to the information in the records, provided they, like other clinicians, undertake to comply with the usual rules on data confidentiality.

The third category poses a more delicate question. It is composed of natural caregivers, volunteers and other non-care personnel who may be closely associated with the care of a sick person, but have no professional qualifications or care mandate from the institution. In general, volunteers do not have access to data, as confirmed by the studies mentioned previously. Besides volunteers, the most difficult case in this category is that of family members acting as natural caregivers, in other words family members or friends who take responsibility for some of the care provided in the home. The EHR could be a source of relevant information for the care given. There is little documentation on this topic.¹⁰ Chaplains must then be careful about the information they enter in the record when natural caregivers are involved in providing care, especially over a long time period.

3.3. Influence on Clinical Judgments

The use of standardized tools is already widespread in the technoscientific clinical culture and office environment of contemporary healthcare institutions and, as a result, there are calls from the world of chaplaincy itself to allow chaplains to participate in electronic platforms. These calls for closer involvement by chaplains in the clinical process, although they tend to show that healthcare institutions can promote and confirm the objective of professionalization,¹¹ nevertheless introduce a constraint that can be seen as the price to pay: the growing standardization of charting practices.

Discussion of this ethical issue – because it affects the quality of the communication of the clinical judgment – must begin with the observation that many different researchers, after looking at the question of charting by chaplains, agree with the push for standardization, in other words the adoption of a “charting model” (Peery 2012).¹² This objective of clinical research in the field of spiritual care, known as outcome-oriented chaplaincy, clearly has links to the movement in support of a form of evidence-based chaplaincy, in other words a focus “on outcomes of spiritual care, the development and testing of effectiveness of interventions, the development and evaluation of assessment and screening tools and research about key subgroups of patients” (Damen et al. 2018, 62).

Standardized charting does not automatically lead to a reductive format or, in other words, a reduction in the quality of the information communicated. It may, on the contrary, encourage chaplains to add information to the file that is significant for the decision-making process. This conclusion emerges from the small number of studies already cited: the use of a template acts as a filter for sorting information that is useful from information that is not. Training in charting ensures that chaplains do not add a mass of descriptive detail that may already be recorded elsewhere in the file but, instead, include elements of interpretation and assessment from each spiritual support situation (Lee et al. 2017, 194–195). Adding notes to an electronic file offers an opportunity to improve the charting procedure. After all, chaplains’ notes may offer a significant contribution to clinical discussion and decision-making (Johnson et al. 2016, 145).

Johnson et al. nevertheless raise a question that is relevant to our discussion. The standardization of charting procedures must not lead to the omission of details that are idiosyncratic by nature (Johnson et al. 2016). They emphasize that charting must allow the inclusion of information that enriches the understanding of the patient’s overall situation. Similarly, standardized charting must not be limited simply to an observation of the current state or a generic and even superficial judgment of the case. Each episode recorded must be part of a biographical progression and personal history that is already under way, for which the record is one element of tangible proof. The interpretation of a patient’s situation can gain from being re-centred over time on the “long term.” This added perspective will certainly improve the accuracy of the decisions made by the clinical team.

In addition, just as the virtues of a narrative approach have been recognized in medical practice (Charon 2006; Charon and Montello 2002), it is clear that a narrative recording of information about the patient for clinical judgment purposes can improve EHR use, provided chaplains are given the opportunity to provide the relevant data. The study by Johnson et al. of free-text documentation by chaplains highlights its impact in improving the decision-making process by recording elements that would be hard to report would otherwise be because they are so deeply rooted in the specifics of the case.

Bringing all the above remarks together, we can suggest that, ideally, any note added to an EHR should provide descriptive elements that are not already included in the record, elements that contribute to the interpretation and assessment of the situation, and elements to situate the clinical case in the patient’s specific life history. This is why the choice of the interface model used in the clinical world is crucial, since it will partly determine the quality of the decision-making process and, ultimately, the appropriateness of the decisions made with respect to the actual case. This is confirmed in the study by Rathert et al. about caregiver/patient communications in the era of electronic health records (Rathert et al. 2017, 50–64). In a review article, the authors show that the use of EHR tools produces ambivalent results: “EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships” (Rathert et al. 2017, 62). This means that the standardization of charting practices may have an influence, via the decision-making process, on care practices and outcomes.

3.4. Ethical Issues Surrounding Recognition

The next issue examined here touches on a fundamental question in the field of ethics: recognition of subjectivity, in other words the fact (and normative ideal) of seeing the other as a subject in his or her own right, and not simply as a means or even an object upon which work is performed. A long philosophical tradition, beginning in the late eighteenth century, has addressed the specific question of recognition.¹³

To summarize succinctly, the “problem” of recognition can be defined as “identifying the conditions, processes and situations that lead to a situation in which Ego and Alter consider each other as equals [in dignity and law] and where the link between them is based on mutual respect and esteem. [...] [The notion of recognition] attempts to encapsulate the origin and consolidation of moral subjectivity in inter-subject relations – within the family, within society – and in the genesis of moral, social and legal relations within society” (Jobin 2013).

Recognition of the other as a subject has an undeniably moral scope since it confirms the other as an autonomous subject. In addition, recognition is expressed in several ways, such as respect for the other’s integrity in interpersonal relations and the equality of all in dignity and in law. But beyond the legal aspect, the process of recognition involves everything that defines the particularity and unicity of individuals or groups in a given society and all that “deserves” esteem. Attention paid to the other as an other, as different from one’s self, a unique being with a singular life path, is a mark of recognition, and the recognition offered in this way is a mark of mutual respect and esteem between individuals who recognize each other with their own specific differences. The link between the ethical question of recognition and the main focus of this text is based, specifically, on the latter aspect of the theory of recognition, and we can group some of the issues raised in the EHR literature under the theme of the ethics of recognition. The following discussion, without referring directly to chaplains, can shed some light on the topic.

Some criticism has been directed at various potentially problematic aspects of EHR implementation. The issue of anchoring a clinical situation in a life story, which can easily be masked by the standardized information required by the interface, resurfaces in an analysis of the political interests that underlie the implementation of templates. “No doubt, EHR interfaces are designed to make their use as efficient as possible, allowing clinicians to choose between checkboxes and radio buttons for predefined options. As EHRs evolve, these embedded layers add up and increasingly require that clinicians, at the time of care, enter a vast amount of highly structured information, much of which may not be clearly relevant to the individual patient” (Hunt et al. 2017, 406). This criticism by Hunt et al. points to the danger of obscuring the patient’s singularity behind the generic information “required” for the EHR. In the end, the authors make the hypothesis that “the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician’s role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.” (Hunt et al. 2017, 418). One unwanted side-effect is the “patient disappearing,” just when the goal is to share as much information about the patient as effectively as possible. The irony of the situation is clearly apparent. The patient, as a whole person, is hidden behind the general data generated by the methods used to investigate, gather and share data in an attempt to take responsibility for the patient.¹⁴

As highlighted by the last quote, the possibility of losing sight of the patient is not just a problem for the patient, but also for clinicians whose role now includes an extra administrative component that may distance them from their primary expertise. Other researchers have made similar observations. Petrakaki et al. claim that the introduction of EPRs (Electronic Personal Records) in England had a clear impact on clinical practice and the cooperative relationship between members of the care team. The research team showed that “EPR affords, as it interacts with healthcare professional practice, some level of standardisation of healthcare professional conduct and practice, curtailment of professional autonomy concerning clinical decision-making and enlargement of nurses’ roles and redistribution of clinical work within and across professional boundaries” (Petrakaki et al. 2016, 221). The point that attracts our attention here is the effect on clinical judgment, which can be perceived negatively by some players in the clinical world. Clinicians’ autonomy with regard to their clinical judgment and active involvement in the decision-making process for a given patient may be affected by the limits imposed by a computer interface. Recognition for clinicians as subjects in their own right also requires respect for their professional autonomy.