The emergency physician and patient confidentiality: A review

CONCEPTS

The Emergency Physician and Patient Confidentiality: A Review These guidelines, prepared by members of ACEP's Ethics Committee, serve as an adjunct to ACEP's policy statement "Patient Confidentiality," approved by the ACEP Board of Directors, January 1994.

Gregory L Larkin, MD, MS John Moskop, PhD Arthur Sanders, MD, FACEP Arthur Derse, MD, JD, FACEP

Received for publication Febt~2ary 22, 1994. Accepted for publication March i0, 1994, Copyright 9 by the American College of Emergency Physicians.

See related policy statement, p 1209. [Larkin GL, Moskop J, Sanders A, Derse A: The emergency physician and patient confidentiality:A review. Ann EmergMed December 1994;24:1161-1167.] INTRODUCTION Confidentiality is a keystone of emergency health care. Codes of medical ethics have long echoed the sentiment that privacy is an important, though not absolute, principle. The American College of Emergency Physicians has supported the importance of this principle; however, ACEP has not articulated definitive guidelines explaining the limits and exceptions to patient confidentiality This policy resource and education paper is an exposition of confidentiality m the context of the emergency physicianpatient relationship. The paper reviews some of the historical, legal, and ethical sources from which this concept has emerged. It presents important reasons for respecting confidentiality, as well as reasons for disclosing confidential information in certain circumstances. Finally, this policy resource and education paper explores some of the challenges of maintainingconfidentiality with employees, the media, AIDS patients, drug abusers, and minors.

DEFINITION

Confidentiality

and confide derive from the Latin confidere, to trust. This etymology is revealing--patients confide in their physicians with the faith or trust that what they report will not be disclosed further without explicit permission. 1 The principle of confidentiality, therefore, enjoins physicians to protect patient reformation (physical, historical, or emotional secrets) from unauthorized disclosure to anyone not directly involved m the patient's care and treatment. Respecting confidentiality has long been acknowledged as a basic professional responsibility of physicians. It may, therefore, be understood as an implicit promise of physicians to their patients.

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HISTORICAL BACKGROUND

Since the ancient Code of Hammurabi (c 2050 BC), physicians have recognized a professional and moral obligation to honor their patients' rights to confidentiality. The frequently invoked Hippocratic Oath, written by the Pythagoreans around the fourth century BC, contains a famous admonition against the breach of confidentiality: "Whatsoever in my practice or not in my practice I shall see or hear amid the lives of men, which ought not to be noised abroad, as to this I will keep silence, holding such things unfitting to be spoken. "2 Tradition notwithstanding, the Hippocratic Oath was not obligatory for Greek physicians of that period (460377 BC), and Hippocratic principles did surprisingly little to ensure the protection of confidentiality throughout the centuries. Despite Cicero's assertion that, "physicians who penetrate into private houses and rooms must hide many things and be silent, even under persecution, ''3 confidentiality was largely ignored until after the Renaissance. Throughout the Middle Ages, for example, patients with plaguelike diseases routinely had their privacy abrogated and their identities publicized. Similarly, those diagnosed with leprosy had to ring bells or clappers to warn others of their approach and condition. It was not until the 19th century that confidentiality finally became widely recognized as an important obligation. The French Penal Code of 1810, for example, imposed imprisonment and hea W fines on physicians who revealed medical secrets. 4 In i803, Thomas Percival established the first modern code of Western medical ethics, which states, "Patients should be interrogated concerning their complaint in a tone of voice which cannot be overheard."5 The American Medical Association's (AMEs) original Code of Medical Ethics, adopted in 1847, was a revision of Percival's work and formally included the principle of confidentiality. The current version of the AMEs Principles of Medical Ethics (also adopted by ACEP) avows, "A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law. ''6 This is reaffirmed in the Report of the Council on Ethical and Judicial Affairs of the AMA: "The patient has a right to confidentiality. The physician should not reveal confidential communications or information without the consent of the patient, unless provided for by law or by the need to protect the welfare of the individual or the punic interest. ''r The Joint Commission on Accreditation of Healthcare Organizations also holds that "...the patient has the right, within the law, to personal and informational privacy. ''s

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Thus, modern physicians continue to recognize the importance of confidentiality, and have included it in various oaths, principles, and rules of professional conduct. Most of these codes commonly hold that confidentiality may be breached only when required by law, when in the public interest, or when necessary to prevent harm to others. LEGAL CONCERNS

Physicians are less influenced today by ancient oaths than by their professional role and the legal milieu in which they work. Emergency physicians must remain cognizant of myriad rules and regulations governing practice in their jurisdiction. The legal duty to respect confidentiality, however, is complicated by the fact that case law has found both for and against confidentiality. On one hand, American common law has found physicians liable for breach of confidentiality on grounds of defamation, invasion of privacy, and breach of an implied contract. 9 On the other hand, physicians have been indicted for failing to breach confidentiality when it was deemed obligatory for them to do so in order to warn or protect others. For example, the courts have found against physicians for failing to warn a third party about a patient's seizures, ~~ failing to warn a third party of the danger of infection from a patient's wound,~l failing to warn neighbors and others living in proximity to patients with contagious diseases, 12-14 and for failing to warn a woman that a patient was contemplating her murder. ~5 Because each case must be analyzed in light of the often contradictory laws of its own jurisdiction, emergency physicians should base their action on ethical principles and not dwell on conflicting legal dicta. It is important to emphasize, however, that legal precedent should not be the sole determinant of moral decision making. When faced with inconsistent or confusing laws, an emergency physician's best course is to act ethically and to minimize harm for all concerned. REASONS TO RESPECT PATIENT CONFIDENTIALITY The maintenance of confidentiality is both a legal and an

ethical duty of emergency physicians. Indiscriminate disclosure of patient confidences may disgrace patients, undermine trust, and seriously imperil patients' relationships with their doctors and others. Patients expect that physicians will honor the implied contract of silence and fulfill their obligation as patient advocates, to This veil of

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secrecy serves as a quid pro quo for each patient's honest and detailed histo~ Confidentiality is particularly vital under the forced circumstances of an emergency encounter in which vulnerable patients have little control over where they go, who they see, or who is on the next gurney The only real control that emergency patients may exercise is over what they choose to reveal. Hence, the alliance with emergency physicians is already severely strained; any additional threats to patient confidentiality would only further erode patients' faith in their physicians. Confidentiality encourages candor, but, once violated, it cannot be restored. Moral arguments for confidentiality are rooted in the principles of utility and duty According to Utilitarian principles, breaching confidentiality may be thought to weaken society's faith in the greater institution of medicine. The resultant distrust threatens the provision Of detailed and accurate information necessary for correct diagnosis and treatment. Thus, possible long-term destruction of patient openness would mitigate strongly against breaches in confidentiality Physicians also have a duty to respect the rights of patients to autonomy and privacy lr This duty to patients generally supersedes any duties to society or others who are not patients. Patients have a strong interest in preventing the disclosure to others of sensitive information about themselves. Physicians' willingness to maintain confidentiality enables patients to retain control over this information. Therefore, confidentiality may be defended on both utilitarian and nonutilitarian grounds, because it not only injects trust into the professional-patient relationship, but it also affirms the patient's rights to autonomy and privacy

lute prohibition against discretionary breaches of secrecy. Similarly, the aforementioned ethical principles of the AMA and the American College of Physicians recognize certain exceptions to the rule of confidentiality 6 Although the specter of litigation fosters a reluctance to honor exceptions to confidentiality, there are, in fact, specific circumstances in which a health care provider is legally required to report confidential patient information. These circumstances come under the penumbra of compelling state interests and include the following: 2~ 9Public reporting statutes (eg, vital statistics [birth and death certificates], contagious and dangerous diseases [including AIDS], child neglect and abuse, and criminally inflicted injuries) ,Judicial proceedings 9Statutes on cost and quality control (peer review organizations, utilization review) 9Patient poses a danger to a known person In general, physicians may disclose confidential information when patients agree to the disclosure or when disclosure is required in order to fulfill a stronger moral duty to prevent harm or to obey the law. Disclosure of information to professionals directly involved in the care of the patient can, in most instances, be understood as having the patient's implied consent. The physician's decision to reveal confidential information in order to prevent harm to the patient or others should be based on the probability of harm, the magnitude of the expected harm, and the possibility of alternative methods for avoiding harm that do not require infringement of confidentiality 19 CONFLICTS AND RESOLUTIONS

REASONS TO BREACH

Moral arguments for confidentiality, however convincing, may sometimes have to yield to stronger grounds for disclosure. This is illustrated most clearly in the case of the potentially homicidal patient. Innocent third parties could be endangered if, for example, a patient told his physician under the promise of secrecy that he was intent on killing his spouse, t8 The gain in confidentiality from either an adherence to an inviolable duty to the patient or avoidance of long-term societal distrust would be dwarfed in this case by the loss of safety to the threatened party. Therefore, despite its vital importance, the duty to maintain confidentiality is best viewed as a prima facie (not absolute) obligation that may be overridden when it conflicts with stronger moral duties, t9 Even the Hippocratic Oath prohibits only revelation of those things "which ought not to be noised abroad" and is itself not an abso-

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Emergency physicians face a variety of situations in which the primacy of confdentiality is called into question. Respecting the wishes of patients when they are at odds with the interests of third parties or society can require an extraordinary degree of moral sensitivity, discretion, and judgment. These conflicts arise in scenarios involving minors, drug testing, AIDS, medical records, employees, and the media. Such situations require careful reflection on the part of the emergency physician. Several conflicts and possible resolutions are discussed in abbreviated form below. Regardless Of the situation, however, physicians must remain cognizant of their professional responsibilities and exercise the utmost discretion with sensitive patient information. Employee Hea{tb When an emergency physician is also the employee health physician, patients may be directed to the emergency department for health screening examinations, treatment of work-related injuries, or drug and

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alcohol testing. In each of these situations, the physician's responsibilities extend to both the employer and the employee/patient. However, even when physicians act primarily as agents of the employer, they still continue to be stewards of patient trust and privacy. Therefore, emergency physicians should obtain informed consent before releasing anything but the most generic patient information. Whenever the employee authorizes disclosure, only the information that is relevant to the individual's ability to perform the work required by his or her job should be released. More detailed information should be made available only when agreed on by the patient, required by law, or when necessary to protect the safety of the patient or others in the workplace. 2~ Certain organizations, such as the armed forces and other governmental agencies, have special rules and regulations regarding the confidentiality of patient information with which employees of these organizations should be familiar. It is appropriate for military physicians, for example, to remind their employee/patients of these special rules before starting evaluation and treatment. Communicable Diseases/STDs/AIDSConfidentiality not withstanding, physicians also have been entrusted with a moral, legal, and professional duty to prevent the spread of disease in society. All states have laws requiring the reporting of certain communicable diseases for public health purposes, and it is imperative that the emergency physician be knowledgeable of the public health statutes where he or she practices. Examples of such diseases include rabies, tuberculosis, diphtheria, and rubella. Sexually transmitted diseases (STDs) have been treated as both personal and public health problems for centuries. 23 Today, most states continue to have statutes governing the reporting of such sexually transmitted diseases as syphilis, chancroid, lymphogranuloma venereum, and gonorrhea to public health authorities. The latter use this information for epidemiologic and surveillance activities aimed at decreasing the incidence of STDs in the population. These activities are generally publicly funded and are deemed to be in the best interest of society at large. Exposed persons are not likely to find out by themselves that they have been endangered, and they are dependent on the efforts of the health department and the index patient for honest and timely intervention. For this reason, contact tracing and partner notification endeavors have been considered "ethically acceptable and epidemiologically necessary" for many years. 24 Nonetheless, it is imperative that these surveillance activities be conducted without betraying the confidence of

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the index patient, and names are not to be released to nonclinicians or contacts at any time. In the ED setting, patients Sometimes are treated without definitive laboratory confirmation of the diagnosis, thereby putting the onus of reporting on the emergency physician. Compliance with just statutes supersedes the patient's confidentiality concerns in this situation, but the patient must be reassured that compliance with the law does not mean that their personal privacy will be violated when public health authorities are notified. Patients should be encouraged to inform their partners and to adopt either safer sexual practices or abstinence until the threat of STD transmission is removed. STD patients also must be warned of the consequences of not informing partners, and their compliance with medications and follow-up should be strongly encouraged. As with other STDs, the diagnosis of AIDS or HIV seroconversion is confidential in the context of a therapeutic doctor-patient relationship. Moreover, it is the expectation of and the reliance on confidentiality that leads seropositive patients to counseling, testing, treatment, and, possibly, behavior change. All 50 states mandate that AIDS be reported to public health authorities. 25 Moreover, the Tarasoff court has warned physicians that, "the protective privilege ends where the public peril begins. 'q5 Thus, if the patient with HIV refuses to remove identifiable others from imminent risk (for instance, by breaking off the relationship, abstaining from sexual intercourse, practicing "safe sex," or warning one's partner of his or her antibody status) the physician has an ethical duty to ensure that the third party is made aware of the high risk of transmission and the need for precautions, counseling, and testing. The AMA's Code of Ethics implies that rights to confidentiality may be abrogated if they "infringe in a material way upon the safety of another person or persons.'6 Guidelines as to how this conflict is to be reconciled have been published in the AMA's Council on Ethical and Judicial Affairs report Ethical Issues Involved in the Growing AIDS Crisis and include the following: When there is no statute that mandates or prohibits the reporting of seropositive individuals to public health authorities and a physician knows that a seropositive individual is endangering a third part}; the physician should: (1) attempt to persuade the infected patient to cease endangering the third party; (2) if persuasion fails, notify authorities; and (3) if the authorities take no action, notify the endangered third party. 26 A similar view is advanced by ACEE which also requires that physicians notify third parties if a seroposi-

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tive patient fails to act responsibly. 2r As much as possible, the identity of the index case should remain anonymous, thereby optimizing both public health and confidentiality. The Media When patients generating media interest arrive in the ED, reporters are likely to follow. In general, physicians should be reluctant to release any patient information without specific permission from a patient, a court order, or an overriding and compelling third-party or state interest. Ideally, both the public "right to know" and the freedom of the press are subject to patient consent. However, it is commonly assumed that, by virtue of their position, public figures must surrender a certain measure of privacy and thereby grant implied consent for limited disclosure. Never does the morbid curiosity of the public supersede the patient's right to privacy; even elected officials deserve to have some control over the type of information to be released to the media. Provided consent is given, the patient's name, sex, address, occupation, marital status, and a general statement of his or her medical condition may be released to the press. 2s In criminal cases, overdoses, and suicidal gestures, no details should be given regarding alleged motive, social status, or hearsay evidence. In cases involving assault or rape, the identity of the victim should not be released. Communications with the police may be essential in criminal cases to ascertain that sensitive information that could hinder investigation and threaten public safety is not disclosed. Medical Records Confidential communications between physician and patient were once as respected as those between priest and penitent. In the present information age, however, this cornerstone of patient rights has become increasinglyjeopardized. To reverse this threat, any electronic or paper record that could possibly be harmful to the patient should be guarded closely. Utilization review and claims processing by third-party payers may violate the spirit if not the actual laws of patient-physician confidentiality Even when patients consent to release information to insurance companies for reimbursement purposes, no information should be released beyond that necessary for paying and collecting fees for services rendered. Similarly, identifiable personal information for research data collection should not be released without the express written consent of the patient or an institutional review board waiver of the consent requirement. 29 Patient consent for disclosure of records should not be nested in the authorization for treatment. Instead, it should be written separately to include the name and signature of the patient, the names and signatures of the parties releasing and receiving reformation, the purpose of the disclosure, the

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type of information to be released, the date, a 6-month expiration date, and an escape clause allowing the patient to revoke the consent at any time. 2~ Physicians should, as a general rule, decline to respond to telephone inquiries for records and should use copiers and facsimile machines with great discretion. An exception to this rule would be the emergency use of facsimile machines or copiers to provide caregivers with important information (eg, ECGs and laboratory results) on patients who are otherwise too ill to give consent. A second exception, which is in keeping with the Consolidated Omnibus Budget Reconciliation Act of 1986, is that copies of medical records must accompany all patients who are transferred from one institution to another. Thus, emergency physicians must balance respect for confidentiality with the medical needs of the patient. Like the computer, the telephone answering machine is also capable of recording and storing confidential patient data and must therefore be used with great prudence, if at all. Emergency providers conducting telephone follow-up should not leave sensitive personal reformation on answering machines because there is little guarantee that such information will not be broadcast to persons other than the intended patient. Obtaining permission from the patient before using the answering machine may be an unrealistic ideal, but simply having the patient return the call may be an acceptable alternative in some circumstances. Minors Although they often lack the financial, social, and intellectual capacity to enter into a doctor-patient relationship on their own, minors also have a right to patient confidentiality. In most circumstances, treatment of minors requires the informed consent of the responsible parent or guardian. Parents are, therefore, entitled to information about their minor childg condition sufficient to provide consent. In specific circumstances, however, such as treatment for STDs, mental illness, and pregnancy, most state laws permit minors to consent to treatment without parental notification. This is important because it has been shown that adolescent minors are more likely to seek medical treatment for STDs and diseases related to depression and drug use if they know their treatment will remain confidential.3~ The legal doctrines of the emancipated minor and the mature minor also allow physicians to respect the confidentiality and independent decision-making capacity of adolescents in at least some situations. 31 This is especially true when the minor demonstrates cognitive maturity both to make decisions voluntarily and to understand the risks, benefits, and alternatives to treatment. 3a Even if disclosure of information to parents is deemed necessary, adolescent minors should be forewarned and, if able, they

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should be permitted to notify their parents themselves. 32,33 The child's welfare must always be protected, but highly personal or embarrassing details should not be divulged. In true emergencies, parents or legal guardians should be notified of the care provided to the child, particularly if there is serious danger of morbidity or mortalitTg Graduate Medical EducationWithin the EDs of teaching hospitals, residents, students, and attending staff often take care of patients together as part of a larger team. Patient information may be shared among the members of the health care team under the doctrine of implied consent. Unless the patient gives consent, however, illustrative cases and photographs used for teaching or research purposes in the medical school or postgraduate setting should omit unnecessary biographical information and protect the identity of the patient. Research protocols also must protect the identity of the patient by using identifiers other than name and birthdate so that confidentiality may be maintained when data are recorded, disseminated, or published. Student Health A university emergency physician may be both an agent of the institution and an advocate for the patient. Like employee health physicians, university emergency physicians may sometimes break confidentiality if they consider it best for the patient, the school, or the community 34 University administrators generally are notified if student patients require hospitalization or attempt suicide as they may be required to act in loco parentis. If the case does not pose a serious threat, notification is unnecessary. Seriously ill students and those threatening to harm themselves or others usually will need to be hospitalized and thereby reported to the university health service, the dean for student affairs, and their parents. Nonetheless, a consent from the student should be obtained whenever possible. Students seeking treatment for STDs, contraception, pregnancy, and substance abuse generally should have their privacy protected against disclosure to their parents and others. These patients frequently use EDs as a way to avoid contact with their parents' (family) physician, and they are usually capable of making informed decisions about their own health care. 32 It may be appropriate to encourage students to notify their parents, but this should not be a requirement for appropriate referral and treatment in the student patient population. Drug Testing Emergency physicians minister to a unique population of patients, many of whom are active lawbreakers. It is perhaps for this reason that they frequently find themselves weighing societal interests against those of the patient. Under the principle of protection of the public welfare and the promotion of the common good, the gov-

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ernment may require disclosure of medical information (blood alcohol and other police tests) for use in the administration of justice. 35 Regulations applying to drugs and alcohol vary widely from state to state. Competent patients generally have a right to refuse medical treatment and the removal of body fluids for testing. If there is a clear medical indication necessitating such testing and the patient refuses, competency may be called into question. Usually there is no obligation to report nonviolent criminal activity to the police, and in the case of drug abuse, federal laws forbid such disclosure when a patient is seeking care for a drug- or alcohol-related problem. Similarly, an arrest warrant is not sufficient for a nurse or physician to draw a blood alcohol test for police purposes, unless consented to by a competent patient or unless an ex parte court order is obtained. Blood alcohol tests should be drawn primarily for medical reasons or when mandated by state law. Drug and alcohol levels obtained in unconscious patients in the course of treatment may be shared with toxicologists and other consultants under the doctrine of implied consent. Otherwise, these levels are confidential and are typically inadmissible in court. If the patient requests a blood alcohol test, it generally should be performed. A person admitted voluntarily can request that there be no notification of kin; however, a person placed in protective custody (often not capable of rational communication) has no such option. Patients should enjoy both confidentiality and, in the absence of Miranda-type warnings, freedom from self-incrimination. Keeping files on drug seekers and communicating with other hospitals regarding these patients are violations of the principle of patient confidentiality; however, there is conflicting opinion as to whether these practices may be justified under some circumstances. Some authorities believe that the use of such data may be permissible provided that the information is accurate, reliable, and helpful for formulating appropriate treatment plans for individual patients. Such files are not part of the official patient record, however, and they should not be shared with anyone other than the patient's physicians. Incapacitated/DeceasedPatients If a person is legally or physically incapable of acting in his or her own interest, disclosures may be made to the extent necessary to protect the best interests of the patient. Federal law mandates the reporting of vital statistics; nevertheless, information regarding deceased patients should not be released by physicians without the consent of the patientg representative, spouse, or responsible family member. Although the deceased themselves cannot be physically wronged, the utilitarian justifications for maintaining confidentiality would still hold. 36

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Disclosure, if warranted, should be conducted discreetly and in such a fashion that would preserve the deceased patientg reputation to the greatest extent possible.

20. Annas GJ: TheRights of Patients: TheBasicACLUGuideto Patients'Rights, ed 2. Washington, DC, Libraryof Congresscataloguing-in-publicationdata, p 175-195. 21. Councilon Ethical and Judicial Affairs of the American Medical Association: CurrentOpinionsof the Councilon Ethical and JudicialAffairs of the American MedicalAssociation. Chicago,AMA, 1986, section 5.09. 22. Lehr RI, MiddlebrooksOJ: Legal implications of employeeassistanceprograms. EmployeeRelat Law J1986;12:262-274.

SUMMARY

Confidentiality is a promise rooted in tradition, law, and medical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients# 4 Although confidentiality is an important principle that should be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require a breach of confidentiality As Beauchamp and Childress noted, "the therapeutic role may sometimes have to yield to one's role as citizen and as protector of the interests of others. ''~9 In general, however, circumstances requiring a breach of confidentiality are rare.

23. Talbot MD: Confidentiality,the law in England,and sexuallytransmitted diseases.Genitourinary /Wed1986;62:270-276. 24. PotteratJJ, Meheus A, Gallwey J: Partnernotification: Operationalconsiderations.Int J STD & AIDS 1991;2:411-415. 25. McDonaldBA: Ethical problemsfor physiciansraised by AIDS and HIV infection: Conflicting legal obligations of confidentiality and disclosure(SpecialtyLaw Digest). Health Care1990;134:7-42. 26. Reportof the Councilon Ethicaland Judicial Affairs of the American Medical Association: Ethical issues involvedin the growing AIDS crisis. Chicago,AMA, 1987(revisedSeptember88). 27. AmericanCollegeof EmergencyPhysicians:AIDS--Statement of principlesand interim recommendationsfor emergencydepartmentpersonneland prehospitalcare providers.Ann ErnergMeal 1988;17:1249-1251. 28. LucashPD, KovalK: The media and the emergencydepartment. EmergencyMedical Services 1981;10:30,32. 29. CurrentOpinionsof the Councilon Ethical and Judicial Affairs of the AMA-1986, w5.07(3),as quoted in FlemingDG, FlemingNS: The erosionof the physician-patientprivilege and patient confidentiality. Health Matrix 1989;7:36-40. 30. Marks A, Malizio J, HochJ, et al: Assessmentof health needs and willingness to utilize health care resourcesof adolescentsin a suburbanpopulation.J Pediatr1983;102:456-460. 31. HolderAR: LegalIssuesin PediatricandAdolescentMedicine, ed 2. New Haven,Connecticut, Yale UniversityPress, p 127-145. -

REFERENCES

32. Councilon Scientific Affairs, American Medical Association:Confidentialhealth servicesfor adolescents. JAMA 1993;269:1420-1424.

1. RossJW: Privacy, confidentiality, and privilege, in Handbook for Hospital Ethics Committees. Chicago, American Hospital Publishing, Inc, 1986, p 82.

33. SharpeG: Valid consent: Determiningthe minor's ability to make decisions. Can MedAssoc J 1977;117:934-941.

2. Temkin O, Temkie L (eds):Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, Johns Hopkins Press, 1967.

34. MeormanJC, UrbachJR, RossDR: Guidelinesfer consultationwith university personnelin student psychiatricemergencies,Journal of American CollegeHealth 1984;33:91-94.

3. McGrew RE: Encyclopediaof Medical History. New York, McGraw-Hill, 1985, p 195-187.

35. US Departmentof Health, Education,and Welfare; SpecialAction Office for DrugAbuse Prevention:Confidentialityof alcohol and drug abuse patient records.FederalRegister 1975;40:20522-20542.

4. French Penal Code,Article 378: Loi du 21 f6vrier 1966 relative au secret professionel. 5. Leake CD (ed): Percival's Medical Ethics. Baltimore, Williams & Wilkins, 1927. 6. American Medical Association principles of medical ethics. American MedicalNews, 1980, 1:9. 7. Report of the Council on Ethical and Judicial Affairs of the American Medical Association, No. XXVl. Chicago,AMA, June 1990. 8. Joint Commissionon Accreditation of Hospitals: Accreditation Manual for Hospitals, 1988, Chicago,JCAH, 1987, p xi. 9. Fruman LS: AIDS and the physician's duty to warn (Part I). Medicine and Law 1991;10:416-443.

36. CallahanJ: Harmingthe dead. Ethics1987;97:341-352. 37. Siegel DM: Confidentiality,in HenryGL(ed): EmergencyMedicine RiskManagemenL Dallas, American Collegeof EmergencyPhysicians,p 181-184. This ACEP Policy Resource and Education Paper (PREP)was prepared under the direction of the ACEP Ethics Committee, with review and comments by James Adams, MD; William Gotthold, MD; Kenneth Iserson, MD; Lewis Silverman, MD; and Gall Anderson, Jr, MD.

10. Lernmoo vFreese, 210 NW 2d 576, Iowa (1973). 11. Edwards v Lamb, 69 Nil 599, 45 A 480 (1899).

12. Skillings vAIlen, 173 NW 663 Minn (1919). 13. Davis v Rodman, 147 Ark 385, 391,227 SW 612, 614 (1921).

14. Jones vStanke, 118 Ohio St 147 (1928). 15. Tarasoffv Regents of the University of California, 551 P2d 334 (1976) Calif Supreme Court, Tobriner M0 (decision author).

Reprint no. 47/1/60201 Address for reprints: American College of Emergency Physicians Sales and Services PO Box 619911

16. Meiohard v Salmon, 249 NY 458 (1928).

Dallas, Texas 75261-9911

17. Bok S: Lying,"Moral Choicein Publicand PrivateLife. New York,Vintage Books/RandomHouse, Inc, 1978,p 154-173.

800-798-1822 ext 6

18. ReganRE: ProfessionalSecrecyin the Light of Moral Principles."With an Application to Several IrnportantProfessiens.Washington, DC, Augustinian Press,1943, p 138-148. 19. BeauchampTL, ChildressJ F: Principlesof Biomedical Ethics,ed 3. New York, OxfordUniversity Press, 1989.

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