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Difficulty: HardConfidentiality and Privacy

A 31-year-old man is evaluated in the emergency department for a deep forearm laceration sustained when he punched a glass window during an altercation at a local tavern. He is intoxicated, agitated, and uncooperative. While the physician is suturing the wound, the patient angrily states, "As soon as I get out of here, I'm going to my ex-girlfriend's house and I'm going to shoot her for causing this." He confirms he has a loaded handgun in his vehicle. Later in the interview, he casually mentions that he frequently "beats some sense" into his 8-year-old son when he gets drunk. Laboratory testing, drawn as part of a standard screening protocol, returns positive for *Neisseria gonorrhoeae*. The patient vehemently demands that the physician not share anything discussed or discovered during this visit with anyone.

Which of the following actions involving the disclosure of this patient's information without his consent are legally and ethically appropriate? (Select all that apply)

  1. Notifying local law enforcement and the patient's ex-girlfriend about his threat of violenceAnswer
  2. Reporting the suspected physical abuse of his 8-year-old son to child protective servicesAnswer
  3. Reporting the *Neisseria gonorrhoeae* infection to the local public health departmentAnswer
  4. D
    Disclosing the patient's *Neisseria gonorrhoeae* diagnosis to his ex-girlfriend while warning her of the physical threat
  5. E
    Informing law enforcement about the patient's property damage and alcohol intoxication at the tavern

Answer

The legally and ethically appropriate actions are notifying law enforcement and the ex-girlfriend about the threat of violence, reporting the suspected child abuse to protective services, and reporting the gonorrhea infection to the public health department.
The correct answers identify the three major legal and ethical exceptions to patient confidentiality present in this scenario. First, the patient's specific, imminent threat to shoot his ex-girlfriend invokes the 'duty to protect' (Tarasoff), requiring the physician to notify law enforcement and the intended victim. Second, the patient's admission of beating his 8-year-old son invokes mandatory child abuse reporting laws, which require immediate notification to child protective services. Third, the diagnosis of Neisseria gonorrhoeae invokes mandatory disease reporting laws, requiring the physician to notify the local public health department. All three of these actions must be taken despite the patient's explicit demand for confidentiality.

Step-by-Step Solution

1
Analyze the patient's threat towards his ex-girlfriend.
The patient made a specific, imminent threat of serious harm to an identifiable individual, and he has the means (a loaded handgun).
This meets the criteria for the 'duty to protect' (Tarasoff exception), requiring a breach of confidentiality to warn the victim and police.
2
Analyze the patient's statement regarding his 8-year-old son.
The patient admits to frequently beating his child when intoxicated.
Physicians are mandatory reporters for any suspected child abuse. This requires immediate reporting to child protective services, bypassing patient consent.
3
Evaluate the patient's positive Neisseria gonorrhoeae test.
Gonorrhea is a mandatory reportable communicable disease.
State laws require physicians to report specific infectious diseases to the public health department for surveillance and contact tracing.
4
Evaluate the distractors for inappropriate breaches of confidentiality.
Disclosing the STI status directly to the ex-girlfriend and reporting the property damage to the police are identified as inappropriate.
Exceptions to confidentiality are strictly limited to the specific scope of the exception. The Tarasoff warning cannot be expanded to include STI status, and past minor crimes do not warrant breaking confidentiality.

Key Concept

Exceptions to physician-patient confidentiality include the duty to protect (Tarasoff) for specific imminent threats, mandatory reporting of suspected child or elder abuse, and mandatory reporting of specified infectious diseases.
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Topics

Confidentiality and Privacy

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