The scene

An elderly patient booked an appointment to see his GP about a rash. While there, he also asked for a two-month supply of his medication and explained that he was making 'one last trip' to visit his daughter in Portugal.

The GP expressed her concern about the patient's fitness to fly - he had recently developed severe symptomatic aortic stenosis, and a recent report from his cardiologist had assessed him as having stage III heart failure using the NYHA functional classification system.

The GP checked the UK Civil Aviation Authority (CAA) guidance for health professionals on assessing fitness for flying. She advised that medical oxygen in flight is needed for those with class III heart failure and that the patient should disclose his diagnosis to the airline so that in-flight oxygen could be arranged. She also told the patient he could become seriously unwell and that his life could be at risk without oxygen.

The patient thanked the GP for her concern and said he understood the risks, but that he had no intention of declaring his health problems to the airline because he was worried they would stop him travelling if he did. The GP showed him the CAA guidance and that this indicated he would likely be safe to fly as long as the oxygen was in place. However, the patient repeatedly refused to be persuaded to tell the airline and declined any suggestion that the GP help him do this.

The GP carefully documented all the advice given and that the patient had said he intended to board the flight without declaring his condition to the airline.

At the end of the day, the GP remained troubled by the consultation. She wondered if she ought to try and contact the airline to notify them of her concerns, but recognised she might not be justified in taking this step without consent from the patient.

MDU advice

The GP spoke to an MDU adviser and they discussed the concern that the patient's health - and possibly his life - could be at risk if he took the flight without in-flight oxygen being provided. The GP was also concerned that other passengers might suffer financial loss and inconvenience if the flight were diverted.

The issue was if the GP could justify any disclosure about the patient to the airline in the absence of his consent, and the GP and MDU adviser agreed that the GMC's publication on confidentiality was helpful when considering this case.

The starting point was that this was an adult with capacity who had been appropriately informed of the risks to his health and life if he failed to disclose his medical history to the airline. In this situation, the GMC guidance says that doctors should usually abide by a refusal to consent to a disclosure, even if that decision leaves the patient (but no one else) at risk of death or serious harm.

The adviser and GP discussed whether a disclosure might be justified in the public interest, to protect the airline and other passengers from financial loss and inconvenience in the event that a medical emergency caused the plane to be diverted. However, the guidance suggested that a disclosure in this situation could only be justified if failure to disclose the patient's medical condition to the airline "may expose others to a risk of death or serious harm".

The adviser and GP agreed that the flight being diverted would be inconvenient, but unlikely to be viewed as reaching the threshold of 'serious harm'.

The outcome

After discussing the case with the MDU adviser, the GP was satisfied that she had given appropriate advice to the patient. She carefully documented both the advice given and the patient's stated intention to disregard the advice.

After due consideration, the GP concluded that she owed the patient a duty of confidentiality and could not justify making any disclosure to the airline without the patient's consent, even if she was uncomfortable with his eventual decision.

This dilemma is fictional but based on members' experiences and the types of calls we receive to our advice line.

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