Before the Health Insurance Portability and Accountability Act (HIPAA) became law in 1996, medical ethics and professional associations had established principles and guidelines to protect patient privacy and confidentiality. These ethical frameworks laid the groundwork for what would eventually become federal legislation.
The concept of medical confidentiality dates back to antiquity. The Hippocratic Oath, formulated in the 4th century BCE, contains the foundational principle: "Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private."
This principle of discretion and confidentiality remained mostly unchanged for centuries, serving as the ethical cornerstone of medical practice long before formal regulatory frameworks emerged. However, the transition from individual ethical commitment to standardized professional guidelines would take centuries to develop.
Despite remaining true to its foundational roots, confidentiality has changed significantly in recent years. According to a study titled Hippocratic oath: Losing relevance in today's world, “When the oath was formulated, there existed only a tripartite relationship in medicine: between the patient, physician, and illness. This harmony was disrupted by the advent of health insurance, malpractice issues, technology, and pharmaceutical companies.”
In the United States, the first formalized code of medical ethics emerged in 1847 when the American Medical Association (AMA) adopted its Code of Medical Ethics. This document, influenced by British physician Thomas Percival's medical ethics work from 1803, explicitly addressed confidentiality:
"The obligation of secrecy extends beyond the period of professional services; none of the privacies of personal and domestic life, no infirmity of disposition or flaw of character observed during professional attendance, should ever be divulged by the physician except when imperatively required by the laws of the state."
The AMA's early code established important principles that would later influence HIPAA:
The post-World War II era brought changes to healthcare and privacy considerations. The Nuremberg Code of 1947, though focused on medical research ethics, established the importance of informed consent—a concept that would later become central to health privacy regulations.
By the 1960s and 1970s, multiple medical specialty organizations began developing their own ethical codes that included privacy provisions:
The American Psychiatric Association's guidelines from 1973 were influential, as they recognized the sensitivity of mental health information and established stronger protections for psychiatric records than existed for general medical information—a distinction that would eventually be reflected in HIPAA's psychotherapy notes provisions.
The 2013 edition of the American Psychiatric Association's guidelines stated, “Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment... Growing concern regarding the civil rights of patients and the possible adverse effects of computerization, duplication equipment, and data banks makes the dissemination of confidential information an increasing hazard. Because of the sensitive and private nature of the information with which the psychiatrist deals, he or she must be circumspect in the information that he or she chooses to disclose to others about a patient. The welfare of the patient must be a continuing consideration.”
The American Hospital Association (AHA) approached privacy from an institutional perspective. In 1973, the AHA adopted its Patient's Bill of Rights, which included explicit privacy protections:
"The patient has the right to every consideration of privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly."
An NIH article titled Patient Rights and Ethics outlined how “The American Hospital Association (AHA) created the first patient bill of rights specifying aspects of patient relationships with HCPs and HCOs, although it had little enforceability.”
The AHA's framework established important institutional responsibilities around privacy protection that would later be reflected in HIPAA's focus on covered entities rather than just individual providers.
Paper records had physical limitations that provided some privacy protection—they could only be accessed by someone physically present, and copying large volumes of data was challenging.
As healthcare organizations began transitioning to electronic systems, these natural barriers disappeared. The Department of Health, Education, and Welfare (now Department of Health and Human Services) recognized these challenges in its 1973 report, "Records, Computers, and the Rights of Citizens," which proposed a Code of Fair Information Practices. The Code rests on five basic principles - principles that would become central to HIPAA decades later:
The American Nurses Association (ANA) made contributions to privacy ethics through its Code for Nurses, first adopted in 1950 and regularly updated since. The nursing perspective brought important aspects to privacy discussions, including:
Different sector-specific laws emerged, each addressing different aspects of health information:
The AMA's updated guidelines addressed computerized records and included detailed provisions on:
The Joint Commission (formerly JCAHO) included privacy requirements into its accreditation standards for healthcare organizations. These standards required hospitals to:
When HIPAA was being developed, its architects took inspiration from decades of professional ethics development. Elements of professional ethics that directly influenced HIPAA included:
Ancient principles like those in the Hippocratic Oath laid the foundation for modern health privacy, emphasizing confidentiality in patient care.
HIPAA strives to protect privacy while allowing necessary information flow for healthcare delivery and public health.
The transition to electronic health records eliminated natural privacy barriers, raising concerns about data access, misuse, and the need for new security measures.
HIPAA's focus on "covered entities" shifted responsibility for privacy protections from individual healthcare providers to the organizations and institutions managing patient data.
The 1973 report highlighted the risks of electronic records and proposed principles for protecting personal data, which later influenced HIPAA's privacy regulations.