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The community of the excluded: mental health and confidentiality in prisons
  1. Gwen Adshead
  1. Correspondence to Dr Gwen Adshead, Forensic Psychiatry, Ravenswood House, Knowle, Fareham, Hampshire PO17 5NA, UK; gwen.adshead{at}southernhealth.nhs.uk

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The thought provoking paper by Elger et al1 addresses a real and common issue for healthcare professionals who find themselves working outside traditional healthcare environments and in communities that may have very particular values and purposes. The authors set out to explore how mental health professionals (MHPs) deal with the ethical dilemmas that arise in situations where the disclosure of personal information might prevent harm, but would violate traditional duties of confidentiality. They gave MHPs who work in prisons a set of four vignettes: two that suggested that disclosure might prevent harm to the prisoner himself, and two where disclosure might prevent harm to others. They then analysed the responses of the MHPs and presented them in this paper. Teasingly, this paper only reports on the decisions relating to disclosure that prevented harm to the prisoner himself; I imagine another paper will deal with the other vignettes.

Confidentiality or a duty to disclose?

Discussions about medical confidentiality traditionally go something like this: Healthcare professionals are held to be under a duty of confidentiality. This ethical duty is generally justified with reference to the good consequences that follow from it; that is, patients are more likely to disclose their problems accurately if they believe the doctor will keep their information confidential and, by extension, that harm may ensue if patients will not share important clinical details. In addition, it is usually argued that personal information is part of personal identity and an expression of autonomy: respect for a person's individual autonomy entails treating personal information about him or her with respect. However, the duty of confidentiality is not absolute. There is no duty to provide patients with ‘secrecy’; only a duty to keep personal information private, and not to disclose it without the patient's permission.

Risk reduction has become an accepted justification for breach …

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