On confidentiality

Asks Pierre Corneille:

I know you’ve discussed this somewhat in a recent post, but I’d like to hear more (if you’re willing) about how you balance your adolescent patients’ need for privacy and confidentiality with their parents’ “right” to know what’s going on with their child(ren).

For example, if you know that the children use drugs, when, if ever, do you tell the parents? Or if you know the children are sexually active and are being reckless or dangerous, do you ever break confidentiality. Or if those are too specific to what *you* do, what are the protocols as you understand them.

No worries, mate.  I’m always happy to return to a familiar topic.

I almost never, ever violate confidentiality.  It is among the tenets I consider most important to preserve in my practice, without which I cannot set my bearings.

Let’s start with your examples — if I know that an adolescent is using drugs, it is highly unlikely that I will disclose that to a parent.  As I’ve written in the past, I won’t even order a drug test without a patient’s assent.  If I were to speculate about what circumstances would need to pertain in order for me to disclose drug use, there would have to be a significant degree of exploitation, naiveté and youth before I would violate confidentiality.  If a fifth grader were using drugs pushed by an older adolescent or adult lurking around their schoolyard, I would disclose that.  But if someone is voluntarily using drugs for their own pleasure, I wouldn’t disclose it.

Similarly, if an adolescent is sexually active, I will not disclose it, even if the patient is engaging in sexual activity that I would consider high-risk.  If the patient has been sexually assaulted, I understand the law to mandate that I report it.  But if the sexual activity is voluntary, I won’t tell.  Were I to have serious questions about the patient’s capacity to consent to sexual activity, I might consider disclosure if there were a significant concern about coercion or exploitation.  That said, genuinely voluntary sexual activity stays private.

I don’t have so a protocol per se, but rather a benchmark.  If a patient is an imminent threat to him/herself or someone else, then it gets disclosed.  Patients are told when I start my spiel about confidentiality (which I give to all of my adolescent patients, at least when the topic is new to them) that if they tell me they are going to hurt or kill themselves or another person I have an obligation to disclose it.  Homicidality or suicidality are disclosed without hesitation.  If the patient or another person is in imminent danger, I cannot keep that information protected.

But if they’re not?  Then my obligation is to the patient and his or her wishes.  If they cannot be assured that their secrets are safe with me, whyever would they entrust them to me?  If I am perceived as an agent of their parents or other authority figures and a threat to their autonomy, how can I expect that they will give me the information that I need to take care of them?  I set bright lines around confidentiality because without them patients must guess at my intentions.  They need to know that they are, in a sense, in a safe space.

Now, if I know a patient is using a pile of drugs or having sex with skeezey older guys, will I strongly, strongly encourage them to disclose it to someone else and seek help?  You bet.  I will try like hell to get them to tell some trusted adult, and to recognize the risks that they’re taking.  I hate being the keeper of dark secrets, and will spend lots and lots of time with patients trying to help them see why they should consider telling someone else what’s going on with them.  But if they refuse?  Then they refuse.

Being a medical provider often involves being in uncomfortable positions.  If you take care of real human beings, you are forced to confront their real human problems.  Sometimes you have to stack one set of ideals against another.  The decisions are sometimes not easy.  But in my practice, the ideal of respecting patient confidentiality is nigh unto sacrosanct, and I preserve it under almost all circumstances.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. If the patient has been sexually assaulted, I understand the law to mandate that I report it. But if the sexual activity is voluntary, I won’t tell. Were I to have serious questions about the patient’s capacity to consent to sexual activity, I might consider disclosure if there were a serious concern about coercion or exploitation. That said, genuinely voluntary sexual activity stays private.

    So let’s say you had a 15 year old patient. Mature for her age. Purposefully sought out birth control so that she could have sex as responsibly as possible. Good head on her shoulders. You find out her boyfriend is over, which makes the sex illegal…

    You don’t have to report it? I’m assuming that, judging by the comment, if it’s in a gray area you are personally disinclined to do so?

    I actually asked Clancy about this very thing a few weeks ago. She said that if the circumstance arose, she’d have to look up what the requirement is, but that she generally doesn’t find out details like the boyfriend’s age. But if she did, she’d have to look it up, and if she didn’t have to say anything, she wouldn’t since she doesn’t want such things to prevent kids from seeking birth control.

    I am pondering a post on AOC laws, which is one of the reasons I ask.

    • I’ve had somewhat simalar situations in teh mental health field. Considering whether a 15 year had a good head on their shoulders should be irrelevant to whether a law has been broken. “Good head on shoulders” is effectively indistinguishable from going to the same church/obeying same social or cultural mores/being a member in good standing of your tribe. I’m overstating , but only a little. Mandatory reporting laws were put in place to take biased/ involved people out of the role of making decisions about what should be investigated.

      • I think my question was more “Is it based on whether laws are broken?” or “Is it based on a threat assessment?” Doctors have to report some things that are legal, and don’t have to report some things are illegal. I’m not sure what category AOC-breakage falls into, if there is otherwise not a significant threat to the individual.

        From the sounds of it, you’re saying it’s based solely on whether sex laws are being broken?

    • I would probably not report, unless there was a clear and actionable violation of the law that mandated reporting. The answer varies from state to state.

      If the girl is 15 and her boyfriend is 19, there is no way I’m reporting that. It may be a technical violation of the law, but I know with certainty that the local law enforcement will never bring a case against the boyfriend (assuming all else is kosher). If the boyfriend is 42, then I’m more likely to disclose. But there is nothing to be gained from demolishing my relationship with the patient for a scarcely actionable statutory violation.

      • “If the girl is 15 and her boyfriend is 19, there is no way I’m reporting that. It may be a technical violation of the law, but I know with certainty that the local law enforcement will never bring a case against the boyfriend (assuming all else is kosher).”

        Don’t be so sure. I’ve read many stories of young adult (and sometimes not even adult but “old enough”) males having their lives ruined because of consensual sexual relationships with underage girls. There is often another element, such as an overzealous prosecutor, a grandstanding father, or, in at least one story, a racial element (black boy, white girl).

        To me, this is all the more reason to NOT report it if you know the relationship is otherwise on the up-and-up. I’m very squishy on statutory rape laws and see arguments on both sides. I’m not at all squishy on ruining young people’s lives because of a well-intentioned, consensual relationship.

        • I think the problem is in knowing the quality of the relationship. The public face of relationships is obviously different from the private face. If you add in the types of coercion and power differentials that can go into relationships, espcially those with teens, its truly hard for an invovled observer to figure it out. I’ve seen some very funky/sleezy relationships ( heavy drug use, prostitution) involving underage teens and those over 18. yeah i’ve seen good ones also, but its something to be careful of.

          • Careful of, yes. I won’t argue with that. But this is an area where I am very much in favor of discretion under the law, something I tend to generally oppose. Hopefully, the doctor and/or other adults in the patient’s life will pick up on signs of something truly damaging in the relationship, such as heavy drug use or prostitution. But a 19-year-old going to jail for sleeping with his 17-year-old girlfriend whom he’s been with for 3 years? Holy f’ing cow.

          • Let me clarify — unless there is something clearly coercive or otherwise pathological about the relationship, it is highly unlikely I would disclose.

        • Yeah, I had this thought, too. They do bring cases forth. It’s especially problematic when it’s a slam dunk case. I mean, you have an underage girl pregnant with an adult’s baby, or you got the girl to admit it before she realized the consequences… automatic conviction. A lot of prosecutors would go for that.

          That being said, they’re probably less likely to in a case where a doctor dropped the dime. Especially if he or she mentioned that it was illegal ahead of time, so that she knew not to cooperate. You could massage the situation.

          Even so, I very much appreciate Doc’s desire to steer clear. In case it isn’t obvious, I think a lot of these laws do more damage to the defendant than the defendant ever did to the victim.

  2. Russell,

    Thank you very much for your answer. Another question (and again, only if you wish to go there): what would you do about a child who self-injures, but not with an intent to commit suicide?

    I ask, because I had close friends growing up who self-injured–not cutting, although I understand that’s the most common type of self-injury practices–and I wonder how their confidentiality might have fared if they had reported it. I suppose your answer would go along the lines of the imminence of the threat: cutting near the arteries is probably more “imminent” harm than punching or scratching oneself, although the one can result in broken limbs and the latter can result in infections. (I apologize to the other readers if this is too graphic.)

    • Self-injurious behavior is a softer call, and one I tend to make on a case-by-case basis. The more significant the self-injury, the more likely I am to break confidentiality.

Comments are closed.