Confidentiality and Duty to Warn

Case Description: Confidentiality and Duty to Warn 

You are a psychologist treating a 22-year-old man with a history of depression and generalized anxiety who works in retail. He is despondent because he has learned a young woman, Susan, who works the counter with him, is dating another man. In the past he referred to Susan as his girlfriend. However, when you queried him about that he described her friendliness at work, not situations you would consider dating. He says her new relationship is “not right.” He shares a fantasy of stalking Susan and her new boyfriend on a date and suddenly appearing in order to “catch” them and give them a “good scare.” When you ask if he ever desires to hurt them, he says no, just to scare them. 

What should you do? 

Discussion of Case: Confidentiality and duty to warn 

Get the facts. 

• Might additional questions help to assess the likelihood of the patient becoming violent? How might you ask them? 
• You may feel torn between duties to respect your patient’s confidentiality and to protect Susan and her boyfriend, if you worry that your client’s fantasy indicates any potential for violence. 

Identify tensions between ideals. 

Identify Options: 

• Continue to counsel your client, trying to assess whether he intends to act on his fantasy and encouraging him to think about the negative consequences of doing do. 
• Warn Susan that your client has a an obsession with her and her boyfriend, and has threatened to “scare” them on a date. 
• Other? 

Duty to warn? This case is difficult because it may not be clear whether the patient is indicating a “direct threat of harm,” the legal standard for duty to warn established by the Tarasoff case. But health care providers ethically may feel an obligation to protect others whether that legal standard is clearly met or not. They also ethically may desire to protect others without violating patient confidentiality if at all possible. Maintaining confidentiality is generally both a way of respecting patients as persons and of maintaining trust in the doctor-patient relationship. In this case, how long the therapist has been working with the patient and how well she knows him legitimately may affect her judgement of whether there is a serious threat. 

The Ethics in Medicine Program at the University of Washington proposes a helpful test: “In situations where you believe an ethical or legal exception to confidentiality exists, ask yourself the following question: will lack of this specific patient information put another person or group you can identify at high risk of serious harm? If the answer to this question is no, it is unlikely that an exception to confidentiality is ethically (or legally) warranted. The permissibility of breaching confidentiality depends on the details of each case.”3 

If you interpreted the case as a strict dilemma, how could you minimize infringement? 

If you decide to warn Susan, how could you minimize or repair the infringement of confidentiality? 

• Only tell Susan what you feel necessary to warn her and her boyfriend. This need not include the full history of your client’s discussions about her. 
• Consider telling your patient his fantasy is so frightening to you that you felt ethically obligated to warn Susan. This option clearly would pose a danger of ending your relationship with the patient. It would have to be weighed against the harm of that possibility, and the likelihood of whether you could convince him to continue therapy with a referral if he did not wish to continue with you.