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  1. Beenthere2Hippie
    When should a doctor betray a patient’s confidence? This week the Supreme Court of the State of Washington heard arguments on this question in a case that has profound implications for the doctor-patient relationship.

    In the case, Volk v. DeMeerleer, a psychiatrist, Howard Ashby, was sued after a patient of his, Jan DeMeerleer, shot and killed an ex-girlfriend and her 9-year-old son before killing himself. (Mr. DeMeerleer also stabbed another son, who survived.) The estate of the victims, Rebecca and Phillip Schiering, took legal action, arguing that Dr. Ashby was liable because he had not warned the Schierings. A lower court ruled in Dr. Ashby’s favor on the grounds that Mr. DeMeerleer, who had occasionally voiced homicidal fantasies, had made no specific threats toward the Schierings during his treatment.

    But last November an appeals court reversed that judgment, asserting that doctors could be required to warn “all foreseeable victims” of potentially dangerous patients in their care. Whether the attack on the Schierings was foreseeable, the court said, should be decided by a jury.

    Though the murder of innocents is obviously a tragedy, the Washington State Supreme Court should overturn the appeals court’s decision. Not only does that judgment greatly expand the circumstances in which psychiatrists would be required to violate patients’ confidentiality; those violations in the end would also not serve the purpose for which they were intended.

    Throughout history, doctor-patient confidentiality has been a cornerstone of Western medical practice. The duty to keep patients’ information private is written into the codes of ethics of medical organizations, and is even in the Hippocratic oath: “What I may see or hear in the course of treatment,” it says, “I will keep to myself.”

    Patients allow physicians into their private lives on the condition that the information we learn will not be used against them. I once took care of a business executive in the emergency room who had hired call girls during a weekend drug binge. When he saw a police officer outside his room, he quietly handed me an envelope containing a large amount of white powder. I wasn’t sure what to do with it, so I discarded it. For the next several hours the patient eyed me suspiciously, probably wondering whether I had ratted him out. But it never occurred to me to do so.

    Of course, like all ethical imperatives, doctor-patient confidentiality is not absolute. Doctors have to disclose private information when it is clearly in the patient’s interest (documenting a drug allergy in the medical record, for example) or when it comes to complying with a court order (as in cases of child abuse). We must also betray confidentiality when it is in the “public interest” (reporting infectious diseases, for example).

    The duty to warn third parties in danger is also an important exception to confidentiality. We publicly disclose the identities of sex offenders. We alert family members when hereditary diseases in our patients come to light. A colleague of mine once took care of a patient, a school bus driver, who received an implantable defibrillator after suffering cardiac arrhythmias. When my colleague advised the man to quit his job because of the potential risk to young children, the man refused, so my colleague reported him to the Department of Motor Vehicles. It was an action that my colleague felt very comfortable taking, even though it created an irreparable rift in that relationship.

    In the same vein, doctors have a duty to warn individuals who are threatened by their patients with bodily harm. This obligation was largely shaped by the seminal 1976 case of Tarasoff v. Regents of the University of California, in which the Supreme Court of California ruled that mental health professionals had a responsibility to protect the intended victims of their violent patients through direct warning or by notifying the police. As Justice Matthew Tobriner famously wrote in the majority opinion, “The protective privilege ends where the public peril begins.” The case has served as a basis for law in 33 states obligating physicians to warn or protect third parties.

    However, the Tarasoff case has generally been interpreted to confer an obligation to warn individuals who are specifically targeted by psychiatric patients. The lower court in Washington observed that Jan DeMeerleer communicated no threats toward the Schierings during his treatment. Predicting when violence will occur or where it will be directed is difficult under the most straightforward of circumstances. When the threat is not articulated, it is next to impossible.

    The World Medical Association states that confidentiality may be breached when the expected harm of maintaining privacy is believed to be “imminent, serious” and “unavoidable.” This standard does not appear to have been met in the case before the Washington Supreme Court.

    Breaching doctor-patient confidentiality in such situations will likely be self-defeating. Mentally ill patients may not seek treatment, and psychiatrists, saddled with new legal liabilities, may decline to treat them. We are more likely to minimize harm if the confidence of patients at the greatest risk for violence is maintained.

    Sandeep Jauhar, a cardiologist and a contributing opinion writer, is the author of “Doctored: The Disillusionment of an American Physician” and “Intern: A Doctor’s Initiation.”


    This op-ed piece seemed a subject of interest to many on DF, so I'm sharing. -BT2H

    By Sandeep Jauhar - The NY Times/Nov. 19, 2015
    Photo: Alex Proimos, flickr
    Newshawk Crew

    Author Bio

    BT2H is a retired news editor and writer from the NYC area who, for health reasons, retired to a southern US state early, and where BT2H continues to write and to post drug-related news to DF.


  1. Nosferatus
    I believe doctors are already required to inform police and child protection agencies when a patient poses a threat to themselves or others or abuse is reported, and that should be enough, unfortunately you can't predict every bit of erratic behaviour, unless the patient admitted homicidal thoughts right before doing this, what could the family have been warned about, I'm also quite certain that the doctor was not the only person aware of the patient's propensity for violent behaviour, people seldom go from completely non-violent to homicidal, there's generally quite a bit of build up between those two points.
  2. Beenthere2Hippie
    I cannot help but believe that patient/doctor confidentiality is the cornerstone on which the relationship is based, and allowing doctors to legally share patients' information with police and/or other authorities is highly problematic.

    I don't think I need to explain why problematic, but maybe I'm wrong, since I can see by Nosferatus's post that not all agree with the premise.

    I'm hoping some good debate points will follow.
  3. Bango Skank

    ^ My exact thought and belief on the issue. I can't imagine any other reasonable exception to this.

    That is awful what happened to those people, and I really do hurt from hearing about it, that poor little boy :'( just tragic.

    However I'm really failing to see how that doctor can possibly be held accountable. Do these people honestly believe that the doctor wouldn't have tried to save a 9 year old boy and his mother, if he had known? Especially since if he knew, all he would've had to do was make one phone call to put a stop to it. I'm not buying it. Unless this psychiatrist was a sick fuck with the heart of a monster, he would have alerted the police if he had any idea.

    I'm thinking that the victim's family are very hurt and very angry that since the man committed suicide there is nobody alive that can be punished in criminal or civil court, and they're reduced to grasping at straws in an attempt to feel some sort of justice and closure. I'm afraid I really can understand these feelings, but it's not right to paint this doctor as the bad guy when he's done nothing wrong.
  4. gonzochef
    Not only is it wrong to blame the doctor, if it is successful then it could completely change the face of psychiatric medicine and the confidential nature of the doctor-patient relationship as we know it. I for one know that if I had no secure guarantee that what I share in private sessions with my doctor could become public then I would just stop getting treatment. I completely agree that if I am in immediate danger of harming myself or others that that is a worthy exception, but anything else is just speculation and assumption on the part of the doctor. That shouldn't be their job, or their responsibility. Yo can't read minds or see the future, regardless of how well you know a person. It was made quite clear that this person, while in therapy, admitted to having homicidal thoughts but not toward a particular individual. I'VE had homicidal thoughts before, and if I had been locked up for them they probably would have come to fruition rather than having the opportunity to sort out my anger.
    Confidentiality is the cornerstone of psychiatric medicine, as well as all medicine in my opinion. People will refuse treatment if they fear a breach of their confidentiality. This is an absolute shame what happened to these people, and the man that committed murder and suicide must have been a very troubled individual and in a way I feel sorry for him too. But there is no way in Hell that it is the fault of the doctor trying to treat him. That is just a horrible legal tactic that I believe is for exactly the reasons you stated, Bango: loss and grief. That's no excuse to entirely change the system. Without confidentiality, treatment will be less beneficial. This ruling has to be overthrown or it will cause far more harm and damage than good.
  5. Nosferatus
    I believe it has a place in very limited circumstances, namely to prevent the patient from committing serious acts of violence against others. I suppose an argument can be made that it's also right to do so if mental illness might cause the patient to seriously harm themselves as well, but I feel deeply conflicted agreeing with that.
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