Psychologists' perceptions of their duty to protect uninformed sex partners of HIV-positive clients.

The purpose of the present study was to determine whether mental health professionals would breach the confidentiality of HIV-infected patients with uninformed sex partners, and how any such disclosure would occur. Subjects read one of eight vignettes that depicted a patient who refused to disclose his viral status. Results revealed a split of opinion about breaching confidentiality and about the preferred mode for doing so. Neither diagnosis nor mode of viral transmission significantly influenced breaching decisions. Subjects demonstrated a high level of AIDS risk knowledge but only a moderate level of legal/ethical knowledge. Implications of these findings are discussed.     

Clinical training and the duty to protect.

Given that the duty to protect is now a well established clinical and legal expectation, training in professional psychology should assist students in developing conceptual models for violence risk assessment and management. This report presents a training model incorporating recent advancements in risk assessment (such as the assessment of psychopathy), the need for basic legal understanding, and knowledge of specific risk management strategies. Additionally, academic and internship training programs in Michigan were surveyed by telephone about current training patterns. Preliminary results indicated program strengths in general awareness and training in risk factors. However, the data also suggested a need to formalize a faculty role in risk education, improve the training of students in relevant legal information, and establish coherent conceptual models of dealing with potential patient violence. It is argued that improving training of future professionals in this way will improve clinical practice, reduce legal liability, and improve public safety.     

Current analysis of the Tarasoff duty: an evolution towards the limitation of the duty to protect.

In 1976, the Tarasoff case established a new legal duty to protect third parties from a psychiatric patient's foreseeable violence. After the Tarasoff case, courts expanded the scope and role of a clinician's duty to protect, sometimes in novel ways. Later interpretations of Tarasoff began to limit significantly the situations in which a duty to protect would attach. Recent Tarasoff-type cases in which courts have rejected the clinician's duty to warn suggest that Tarasoff is declining in significance. The advent of state statutes that codify the establishment and discharge of Tarasoff duty have contributed to a further limitation of the duty to protect. Lastly, when faced with the management of dangerous patients, we advocate for a thorough, well documented assessment of risk of violence as the best means for addressing concern about potential legal liability.     

The prediction of violent behavior and the duty to protect third parties

A considerable theoretical, empirical, and clinical literature has accumulated on the prediction of dangerous and violent behavior. Despite the pleas of mental health professionals that the prediction of violent behavior is not clinically feasible, courts upholding a therapist's duty to protect third parties have created a legal duty to do so. The first generation of research studies of the clinical prediction of violent behavior focused on long-term predictions in offender populations, of little direct relevance to the setting of outpatient therapy with nonoffenders. More recent clinical research has centered on predictions of imminent violence in noncriminal populations, particularly in the process of involuntary hospitalization, but this reveals relatively low levels of predictive accuracy. Methodologic and ethical factors also limit the generalizability of such work. Given the likelihood that significant numbers of false positive predictions will result, especially in the low base rate population of outpatient treatment, it is suggested that therapists attempt to minimize the antitherapeutic influence of any breach of confidentiality.     

The so-called duty to warn: The psychotherapeutic duty to protect third parties from patients' violent acts

This article discusses the much-misunderstood Tarasoff decision that requires psychotherapists to protect third parties from patients' violent acts. Through a normative approach, the paper analyzes four important issues: what to do when potential victims are unknown; what to do about the fact that the patients' potential for violence may be incorrectly perceived; the value of warning potential victims; and, the problem of discharging potentially violent patients from the hospital. The author proposes that the courts adopt a more flexible substantial departure test in most cases that involve psychiatric negligence.     

The normative and conceptual foundations of a clinical duty to protect

The continuing controversy surrounding the Tarasoff inspired duty to protect as developed by the courts and legislatures has not adequately weighed the jurisprudential foundations of such an obligation. The authors argue that the duty's misguided thrust of social control grounded in character and status seriously violates broad principles of political morality underlying the law of social control. They conceptualize an alternative--a clinical duty to protect--that coheres with these underlying values and the limits of professional abilities. They contend that any extra-clinical intervention on the part of the psychotherapist entails a role transformation requiring independent justification.     

From tarasoff to hopper: The evolution of the therapist's duty to protect third parties

The duty of therapists to protect third parties has gained national attention following the analyses of the California Supreme Court in Tarasoff v. Regents of the University of California in 1974 and in 1976. The assassination attempt by John Hinckley, Jr., has spawned yet another “duty to protect” case (Hopper v. Brady). Utilizing the issues involved in Hopper, this paper discusses the psychotherapists' duty to protect from harm the patients' potential victims. Following an analysis of Hopper, Tarasoff is extensively reviewed. The evolution of Tarasoff within California and other jurisdictions is traced. Finally, an appraisal of the current status of the therapists' duty to protect as applied to Hopper and future cases is presented.     

Unlocking the beauty of the imperfect duty to aid: Sen's idea of the duty of assistance

This paper examines the links between acting upon a duty to assist, responsibility for these actions, and how such actions link with incremental moral duties that can amass as a consequence of such action. More specifically, this paper is concerned with practices of international aid and assistance, whereby public and privately funded donations enable the actions of parties outside of the territorial and jurisdictional boundaries of a community and state to directly influence the functioning of that community, and the incremental moral duties to which such action can give rise. Using a Senian account of the basis of moral duty, it explains how agents are responsible for the outcomes of their acts of assistance, even when mediated through international institutional actors, and how such acts can give rise to accumulative duties and obligations that are not bound or constrained by territorial boundaries or pre-existing special obligations.     

The duty to believe according to the evidence

‘Evidentialism’ is the conventional name (given mainly by its opponents) for the view that there is a moral duty to proportion one’s beliefs to evidence, proof or other epistemic justifications for belief. This essay defends evidentialism against objections based on the alleged involuntariness of belief, on the claim that evidentialism assumes a doubtful epistemology, that epistemically unsupported beliefs can be beneficial, that there are significant classes of exceptions to the evidentialist principle, and other shabby evasions and alibis (as I take them to be) for disregarding the duty to believe according to the evidence. Evidentialism is also supported by arguments based on both self-regarding and other-regarding considerations.     

Ethics, pandemics, and the duty to treat

Numerous grounds have been offered for the view that healthcare workers have a duty to treat, including expressed consent, implied consent, special training, reciprocity (also called the social contract view), and professional oaths and codes. Quite often, however, these grounds are simply asserted without being adequately defended or without the defenses being critically evaluated. This essay aims to help remedy that problem by providing a critical examination of the strengths and weaknesses of each of these five grounds for asserting that healthcare workers have a duty to treat, especially as that duty would arise in the context of an infectious disease pandemic. Ultimately, it argues that none of the defenses is currently sufficient to ground the kind of duty that would be needed in a pandemic. It concludes by sketching some practical recommendations in that regard.     

Effects of tobacco use on non-adherence to antiretroviral therapy among HIV-positive patients in South Africa

This study aimed to estimate the relationship between tobacco use and non-adherence to antiretroviral therapy (ART) in a South African sample. Participants were 1 963 HIV patients who attended a primary care clinic in Pretoria (female = 68.5%; black African = 99.5%; median age = 37.0 years; tobacco users only = 8.6%, problem drinkers only = 14.9%, and tobacco users and problem drinkers = 10.5%). In adjusted logistic regression analysis, tobacco use only was not significantly associated with non-adherence to ART. Alcohol use only (OR: 1.72; CI: 1.26, 2.36) and tobacco use and problem drinking (OR: 2.31; CI: 1.60, 3.33) were highly associated with non-adherence to ART.     

The Morality of Refusing to Treat HIV-positive Patients

ABSTRACT Do physicians and nurses have an obligation to treat patients who are HIV-positive? Although an initial review of the possible sources of such an obligation yields equivocal results, a closer examination reveals a clear obligation to treat. The current risk of job-caused HIV-infection is not sufficient to warrant a refusal to treat. This is so because there exist rationally justified, general social, as well as specific peer expectations, that health care professionals treat HIV-positive patients. These expectations impose moral obligations on doctors and nurses. Moreover there is no sound libertarian argument entitling doctors and nurses to refuse to treat HIV-positive patients. A morally appropriate identification with his or her role would disincline a health care professional to refuse treatment to an HIV-positive patient. The likely source of such refusal is occupational alienation and an irrational reaction to AIDS symbolism.