In which situation can a physician break patient confidentiality, such as when the patient has a contagious disease or expresses intentions to harm someone, and the physician must disclose this information to prevent harm to others?

When Patient Confidentiality Can Be Broken

A physician can break patient confidentiality when the safety of others can be affected. 1 This is the only legitimate scenario among the options presented where breaching confidentiality is ethically and legally justified.

Legitimate Reasons for Breaking Confidentiality

Harm to Self or Others

• When a patient reports active suicidal ideation
• When a patient reports plans to harm others
• When there is evidence someone is harming the patient
• When the patient poses a risk to public safety 1

Mandated Reporting Situations

• Child abuse or neglect
• Reportable communicable diseases that pose public health risks
• Gunshot wounds and certain other injuries requiring legal reporting 1

Specific High-Risk Scenarios

• Escalating substance use patterns linked with dangerous behaviors (e.g., driving while intoxicated)
• Severe self-injurious behaviors that pose significant risk 1
• Genetic conditions where family members are at high risk of serious harm that could be averted through disclosure 1

Decision Framework for Breaking Confidentiality

1. Assess severity and imminence of harm

   • Is the potential harm serious and foreseeable?
   • Is the risk imminent or ongoing?
   • Are specific individuals or groups identifiable as potential victims? 1

2. Evaluate intervention effectiveness

   • Would disclosure actually prevent harm?
   • Is there an effective intervention available? 1

3. Attempt to obtain consent first

   • When possible, inform the patient of the need to break confidentiality
   • Try to involve the patient in the disclosure process
   • Give the patient as much control as possible over how information is shared 1

4. Minimize disclosure

   • Share only what is necessary to prevent harm
   • Limit who receives the information to only those who need to know 1

Common Pitfalls to Avoid

• Breaking confidentiality for non-safety reasons (e.g., because the patient is a VIP, for case reports, or due to family pressure) is unethical and potentially illegal
• Failing to inform patients about limits of confidentiality at the beginning of the clinical relationship
• Disclosing more information than necessary to prevent harm
• Not documenting your reasoning and actions when breaking confidentiality

International Consensus

Most jurisdictions permit limited disclosure of confidential information without patient consent when:

• The potential harm to at-risk individuals is grave and imminent
• There is a possibility of effective intervention
• The consequences of non-intervention are serious 1

While some jurisdictions maintain absolute confidentiality without exception, the majority recognize that in exceptional circumstances, the duty to prevent harm may outweigh the duty to maintain confidentiality 1.

Legal Precedent

The landmark Tarasoff case established that a duty to warn exists when:

1. The physician has a special relationship with the person who may cause harm
2. The potential victim is identifiable
3. The harm is foreseeable and serious 1

This principle has been extended in some jurisdictions to include genetic risks and other scenarios where disclosure could prevent serious harm 1.