Navigating confidentiality with suicidal youth

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Confidentiality has long been a cornerstone of professional ethics; in medicine it can be traced all the way back to the Hippocratic Oath. It stems from the recognition that patients (or clients) will reveal very personal and sensitive information to professionals caring for them.  Why does that give rise to an ethical obligation to keep that information confidential?  One reason is that it is disrespectful to reveal personal information about someone without their permission, and that is particularly true when the information is especially sensitive and personal.  It is that person’s information and he or she should have control over how and to whom it is shared.

The second reason could be described as instrumental in nature: confidentiality actually contributes to a more effective therapeutic relationship. In order to get the help they need, patients must feel comfortable to reveal sensitive information; and they will only feel comfortable doing so if they can trust the professional to maintain confidentiality. Studies have shown that confidentiality is very important to adolescents, for example, and will directly influence their willingness to seek out professional care.  The importance of being able to control one’s personal information is such a strongly held value in our society that it was given additional legal entrenchment in 2004 with the introduction of Ontario’s Personal Health Information and Protection Act.

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As important as confidentiality is, professionals are also very acutely aware that confidentiality has its limits. Specifically, the right to control one’s personal information becomes limited when that right bumps into other important interests, such as public safety and protecting people from harm. In some cases the limits are mandated by law, which are known as “duty to report” or mandatory reporting circumstances. The most well-known examples include the duty to report suspected child abuse or neglect and the duty to report certain communicable diseases.  The College of Physicians and Surgeons of Ontario Policy on Mandatory and Permissive Reporting actually lists a total of 18 mandatory reporting circumstances.

However, mandatory reporting circumstances are not the only circumstances in which professionals are justified (and perhaps ethically, even if not legally, obligated) to violate confidentiality. Other situations will arise that represent a conflict between confidentiality and public safety or prevention of harm and if there is no legal duty to report, professionals will have to make an ethical judgment about whether violating confidentiality is warranted.

The Canadian Medical Association Code of Ethics has a nicely worded statement to this effect: “Disclose your patients’ personal health information to third parties only with their consent, or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or, in the case of incompetent patients, to the patients themselves. In such cases take all reasonable steps to inform the patients that the usual requirements for confidentiality will be breached.”

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Caring for adolescents who may be suicidal is one of those difficult situations that requires ethical judgment. At what point, if any, should the professional communicate his or her concerns to the parent(s) of an adolescent patient?  It doesn’t fall into one of the mandatory reporting categories, so the question is whether it falls into the category of “permissive reporting” circumstances, to borrow language from the CPSO policy.  If a professional is permitted to report, then the ethical question is whether reporting is the right thing to do under those particular circumstances.  It is clearly a case of preventing harm, so there is a valid interest competing with confidentiality.  The task then is to figure out whether the risk is compelling enough to warrant violating confidentiality. This requires a very deliberate risk assessment on the part of the professional. If the risk is compelling, and disclosing one’s concerns to the parent(s) is seen as a necessary and effective way to minimize that risk, then violating confidentiality is justified.  In such cases professionals are encouraged to consult with people who can help clarify their legal and ethical responsibilities, such as their professional college, the CMPA, and an ethicist (if they have access to one).

One more comment is worth making. Professional guidelines strongly recommend that the topic of confidentiality and its limits be discussed with patients at the initiation of the therapeutic relationship so there are no surprises later on. That way, patients will know up front that despite every effort to maintain confidentiality, situations may arise when other obligations will override it, and they are given an opportunity to consent to that arrangement up front. A study published in JAMA showed that when a health visit starts with a brief discussion about confidentiality, adolescents are more willing to disclose sensitive information and more likely to return to that professional for care. As the saying goes, an ounce of prevention is worth a pound of cure.