Friday, November 20, 2015

In Confidence

As this is a case in my backyard I am not surprised that I read about in the New York Times.  A couple of years ago a young man in the hipster area of town had a meltdown and it led to Police called and ultimately his death.   Not the first in many cities as we know the Santa Barbara area mass shooter had been visited by the Police at the request of his parents concerned he was a danger to himself and possibly others.

The law enables any Physician or Therapist/Licensed to Professional  to contact law enforcement if they believe that their patient is capable of such.  It is called "Duty to Warn" or "Duty to Protect"  This law differs in many states but in this case and in this State it is mandated by law.

We already have States adding to this, drug use and positive drug or alcohol tests to law enforcement for varying reasons, often leading to children being removed from the home or being arrested for another warrant unrelated to the cause or reason for treatment.  The Police already have a reciprocal if not co-dependant relationship with Doctors and Nurses to be complicit in warrant-less blood/urine draws so having access to mental health diagnosis or treatment plans just seems another idea bad to to the bone.

What is not a bad idea is to have members of the force designated mental health evaluators to better handle calls that are about individuals who have demonstrated mental health problems as noted by the callers and in turn that may prevent these individuals from being shot by the Police or in turn place themselves or others in situations where they could in fact do harm with others.

The idea of guns and possession is the other elephant in the room. The right to bear arms is not the right to wreak havoc with said guns. And if the Police believe or are aware that a gun might be in the possession of said individual then no one would complain if with or without warrant they entered the premise with appropriate SWAT, etc to retrieve the weapons. Funny they do that over drugs but not when it is about potential accelerated violence.  So is it the Doctor and his/her lack of information or the fact that Police have no interest in actually doing the job they were hired to do?

When you are in the room and you are ranting, mentally ill, simply volatile or emotional many things are often said in that state. That is the time for the said professional to asses if the patient is in fact simply venting or are actually providing a manifesto or plan of action. Again that is where professional and failure to do one's job is the issue.  I know of a professional "therapist" who complained about his last patient who killed herself immediately after her confirmation that she had no intent of doing so.  Her death was not as import apparently is what I inferred from that, her death was not the problem.  I have little respect for those in mental health gigs as they are often the ones more in need. 

I see nothing good from ringing alarm bells when any patient talks smack. This will not end well regardless.
Protect Doctor-Patient Confidentiality

NOV. 19, 2015
The New York Times
Opinion Page
Sandeep Jauhar

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.

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