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Markkula Center for Applied Ethics

Ethical Tensions: Directness of Harms to Others

The Directness of Harms to Others, as well as to Patient.

All health problems affect loved ones and communities as well as individual patients, but this is all the more so for mental and behavioral health problems. Bipolar or schizophrenic symptoms, depression, anxiety, and post-traumatic stress wreak havoc on intimate, family, friend, and work relationships. Similarly behavioral health habits such as substance, gambling, or sex addiction erode the economic and trust foundations of relationships. Children with mental health challenges may disrupt healthy learning environments in schools. Serious mental illness significantly increases the risk of school drop-out, divorce, job loss, and homelessness. 

Mental illness poses the most direct threat when patients threaten to harm themselves or others. Suicide harms those left behind as well as the immediate victim. At the extreme, serious mental illness can be linked to homicidal inclination. The law recognizes that the seriousness of potential harms can outweigh traditional expectations of confidentiality between patient and health care provider. Direct threat of harm to self or others can be legal grounds for physician-recommended, court-sanctioned commitment to inpatient psychiatric treatment, or other forms of treatment, against the patient will. 

Moreover, the law imposes on health care professionals a special duty to warn others of known threats posed by a patient’s mental health struggles. The famous precedent case establishing this duty is Tarasoff v. Board of University California Regents (1976). Decided by the Supreme Court of California, the case came to be federally influential and widely cited throughout U.S. law. In that case, a mental health patient (treated in a University of California clinic) told his psychologist that he wished to kill a young woman who had rebuffed his romantic interest, Tatiana Tarasoff. Although the psychologist did communicate concerns about the patient’s mental state to campus police, he did not warn Tarasoff or her family of the threat to her. He considered that therapeutic conversation entitled to confidentiality according to legal and ethical conventions of doctor-patient privilege. After the patient murdered Tarasoff and her family post-humously learned of the threat, they sued him for failing to warn the victim. 

The Court found in favor of the Tarasoffs, finding that the threat revealed to the psychologist was so direct that it ethically and legally over-rode doctor-patient confidentiality and the psychologist failed to execute a duty to warn. 

Interpreting Tarasoff’s duty to warn in other clinical cases is very challenging, not only because Tarasoff’s standing as a national precedent has not yet been fully tested in the legal system. Health care professionals may find it difficult to assess, amidst ambiguous information, how direct a threat a patient poses to others--or to self, in cases of suicidal ideation. And undue erosion of norms of confidentiality could discourage people from talking to their healthcare providers about sensitive mental health information. 

Social conversations about potential ethical duties to warn and the challenge they could pose to conventions of confidentiality are broadening. In response to youth suicide, for example, grieving families and teachers have complained that strictly maintained confidentiality between college counselors and just-beyond-minor-age students often proves lethal when the most committed supporters of the young adults are left in the dark about the seriousness of their mental health challenges. With the increasing numbers of mass shootings in schools, Tarasoff-like logic has been expanded to argue that school teachers, guidance counselors, social workers, or fellow students who obtain information they interpret as revealing a risk of violence have a duty to warn authorities. These terrains of unresolved legal and ethical debate generally demonstrate changing community perceptions of tradeoffs between social values and social risks of conventional confidentiality practices. 

Some mental health advocates worry about the extent to which concerns about gun violence influence contemporary social conversation about mental illness. These critics emphasize that most people suffering from mental health challenges are not violent, and that empirical study suggests people with serious mental illness are no more likely to commit gun violence than others.


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