Confidentiality

Abstract

Ethics involves wrestling with difficult, conflicting courses of action. Medical ethics, and psychiatric ethics in particular, is especially challenging, given the need to negotiate a course of action with patients and family. Confidentiality, which is at the centre of psychiatric practice, and is essential if psychiatric treatment is to be successful, has been challenged and even somewhat eroded by legal developments and social change. Psychiatrists cannot promise absolute confidentiality to their patients. While it is tempting to look to ‘the law’ to determine when breaking confidentiality is the ethical decision, psychiatrists must decide whether acting in accordance with the law is the more ethical choice to make when grappling with a difficult clinical situation. The need for strict confidentiality also places constant demands on the psychiatrist to be mindful lest inadvertent lapses in vigilance results in the unethical sharing of patient information. This chapter explores ethical dilemmas in confidentiality in a range of clinical situations involving hospitals, clinics, and private outpatient settings. The unique ethical issues that arise in the treatment of children, adolescents, families, and groups are discussed in detail. The chapter also examines the ethical dilemmas that are often encountered in academic settings, speaking, and publishing. Considerable attention is devoted to the implications of the Tarasoff decision in California and to the Health Insurance Portability and Accountability Act of 1996, which has had a profound impact on the practice of psychiatry in the United States, as well as influencing the law in other countries.