Patient-Doctor Confidentiality Versus Public Safety

Tuesday, July 31, 2012

Over the past few days new details have emerged about James Holmes, the suspected shooter in the Aurora movie theatre massacre. Included is the fact that Holmes was seeing a psychiatrist named Dr. Lynne Fenton prior to the shooting, and that Holmes sent a package to her that his defense team wants handed over.

But should Dr. Fenton, or any psychiatrist for that matter, be required to disclose private information about a patient? And, had she known in advance that Holmes struggled with violent thoughts and delusions, should she have alerted police?

Art Caplan heads the division of medical ethics at the NYU Langone Medical Center. He explores the fine line between confidentiality and safety in therapist sessions. 

"It's a tough, tough problem because the first requirement is certainty, that you really believe that harm to someone is imminent, that it's going to happen soon," Caplan says. "Not some vague threat, not some abstract expression of violence, but an imminent threat. You're also supposed to know against whom or at least where [the violence will occur]." Psychiatrists have to maintain a level of trust with their patients, and reporting everything that their patients say would cause them to lose trust. 

Dr. Paul Appelbaum is a practicing psychiatrist and professor of psychiatry, medicine and law at Columbia University. During his career, he has notified people who have been threatened by his patients, albeit rarely. "I think we're all extremely vigilant [about] inquiring about aggressive histories or thoughts of harming others as part of a routine mental status evaluation," Appelbaum says, and depending on the responses that we get, we will follow up to a greater or a lesser extent in order to determine just how firm and [carefully planned] and likely to be acted on those ideas are."

Caplan cites the 1976 case Tarasoff vs. Regents of the University of California, which arose out of a murder at U.C. Berkley. Prosinjit Podder, an Indian graduate student, became enamored with a woman named Tatiana Tarasoff. She rejected his advances, and Podder fell into depression. In counseling sessions, he expressed his intent to do harm to Tarasoff, and the therapist notified the campus police, but not Tarasoff. Podder then killed Tarasoff, and her family sued the school. 

"The California court said that ultimately, you have to protect patients, you have to protect people who are innocent victims, so if you believe that there really is an imminent threat, you've got to tell not only the authorities, but also the intended victim," Caplan says. The 'Tarasoff standard,' as Caplan calls it, is a landmark case for therapist-patient confidentiality. 

With regards to the case of Dr. Fenton and her patient, Appelbaum believes that the public holds therapists to unrealistic expectations. 

"It is extremely difficult to know when, of the many people who come into our offices, many of whom are angry, many of whom are threatening, that one needle in the haystack patient who will act on those impulses. That's a very, very difficult distinction to make," he says. 


Dr. Paul Appelbaum and Dr. Arthur Caplan

Produced by:

Robert Balint and Kristen Meinzer

Comments [4]

Cyndi from Philadelphia

I found Dr. Applebaum's reference to society's "exaggerated expectations" of psychiatrists to predict violent behavior particularly interesting. In theory, to a non-practitioner (which I am), it appears as if warning signs of violent behavior should be obvious. Psychiatry after all is a "science". The interpretation of the law, discretion of the practitioner, and unique behavior of the patient is a reminder of the complexity of medicine.

I wish that after an tragic event such as the this, that we talked less about the need for more guns and more about issues discussed here today.

Aug. 01 2012 04:18 PM
goy from New England, USA

Anyone considered the glaring fact that Holmes has a degree in Neuroscience, having graduated with Highest Honors?

As such, he is obviously familiar with the symptoms of psychogenic amnesia, which he displayed in almost cartoon fashion during his first televised hearing, and continues to do with his "why am I here?" act.

Holmes planned and executed a remarkably complex and dangerous attack over quite a long period of time, all without being discovered or thwarted. He boobytrapped his apartment with lethal explosives without accidentally blowing himself up or raising suspicion among his neighbors - apparently hoping to create a first-responder diversion in much the same way the Columbine killers did back in '99. This plan and its execution took place over a span of months and involved numerous sensitive details.

As such, there is zero likelihood that Holmes "snapped" or in some other way committed this act due to being "triggered" by, say, his failure in his last exam before departing the program (which exam occurred weeks after Holmes had begun collecting weapons and equipment) because of some "dormant" or "latent" mental illness.

Furthermore, Holmes will have undoubtedly read the details of the Tarasoff case as part of his undergrad work.

There is one very chilling aspect of that case which the author here fails to mention:

Tarasoff's murderer ultimately went free.

That travesty took place, in part, because so much focus was placed on the U of C, Dr. Moore and Dr. Powelson - those who did NOT commit the crime, but ultimately failed to warn Tarasoff - and their responsibility with respect to the murder.

Holmes allegedly sent a description of his intended crime to Fenton. If so, this mirrors the events in the Tarasoff case, where a therapist was given advance notice of violent intent. It's also likely as not that Holmes was aware of Fenton's past reprimands. Evidence shows that Holmes expected to be sent to prison for some crime, having asked online acquaintances if they'd "visit me in prison" weeks or months before executing the final steps of his plan.

All this adds up to a very clear picture of someone who apparently wants to prove that it's possible to match the "achievements" of "The Joker", and get away with it... only in real life, with real people. Unfortunately, it's obvious so far that few have the stomach to look at that possibility, represented by these details, and recognize the pure evil they may reveal.

Most folks would apparently rather focus on those who did NOT commit the crime, for some reason. We'd apparently rather think "society" is responsible for incidents like Aurora, so that someone will pass another law restricting law-abiding citizens' rights, which will do absolutely nothing to prevent the next spree killing.

Just something to think about.

Jul. 31 2012 08:04 PM
Larry Fisher from Brooklyn, N.Y.

Psychiatrists have a high rate of suicide because of situations like this.

I might write a horror story about a Psychiatrist who becomes a Vigilante. He starts killing patients who he thinks will act out on their fantasies. Clint Eastwood as "The Shrink." Before he kills his patient, his catch line will be,"Feel better now?"

It is easy to blame the Psychiatrist after the fact. Most peoples fantasies, no matter how dark need to be protected. Once the patient begins buying weapons and revealing it to the Doctor... the Doctor has to go to the authorities and risk losing his license

Jul. 31 2012 11:17 AM
Phyllis from Aurora Colorado

Was James on drug(s, such as prosac,prescribed by his doctors?
If so,that speaks volumes! All drugs have side effects, but won't be taken of the market because of 'money'!
This reminds me of the Columbine fiasco!

Jul. 31 2012 09:40 AM

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