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Weakening Doctor-Patient Confidentiality Will Negatively Impact Care


The New York Times recently published an op-ed dealing with a case before the Supreme Court of the State of Washington that could have implications for the psychiatrist-patient relationship and for the practice of psychiatry.

In the case that author Dr. Sandeep Jauhar mentions in the op-ed, Dr. Howard Ashby, a psychiatrist, was sued by the estate of victims who were murdered by one of his patients for not warning them that the patient was potentially dangerous. A lower court ruled in Dr. Ashby’s favor on the grounds that while the patient had admitted to homicidal fantasies, no specific threats had been made to the victims. An appeals court later overturned that ruling, and it eventually made it way to the Washington State Supreme Court.

At issue here is a physician’s responsibility to warn “all foreseeable victims” of patients in their care who could be potentially dangerous. However, predicting violent behavior can be extremely difficult or even impossible, especially if no specific threat has actually been made. When a patient expresses homicidal ideation, the appropriate response is to do a violence risk assessment to determine whether the risk of violence is serious and what actions should be taken to mitigate the risk, e.g. increase frequency of sessions, hospitalize, or use medications. It is not appropriate to mandate that all possible victims should be warned.

The potential implications of this case could include new legislation that would require psychiatrists to predict violence and then breach confidentiality unnecessarily by warning all foreseeable victims, even when not specifically identified. The American Psychiatric Association and several other organizations have filed amicus briefs decrying the negative effects such a decision could have on the ability of psychiatrists to effectively care for their patients. In the op-ed, Dr. Jauhar, himself a cardiologist, rightly calls doctor-patient confidentiality a “cornerstone of Western medical practice.” Every day, patients come to us with sensitive information about their personal lives and well-being, and trust us not to use that information against them. This trust is, of course, not absolute, and as physicians we may need to breach it if there is a real, imminent threat to a specific individual. With that said, our primary focus has and always should lie in achieving good outcomes for our patients.

What APA is Doing for You

This blog post is part of an occasional series highlighting how APA advocates on your behalf to support the profession of psychiatry and put our interests before key policymakers.


Post by Renée Binder M.D.

Renée Binder, M.D. is the Immediate Past President of APA. Read Dr. Binder's full biography.

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