When doctors divulge: is there a "threat from within" to psychiatric confidentiality?

Psychiatrists, as a profession, have always asserted the central importance of confidentiality. The American Psychiatric Association (APA), in its recently released "Guidelines on Confidentiality," reaffirms this position. In an age of progressive erosion of the traditional psychiatrist-patient confidentiality, the threat to confidentiality is invariably perceived as exogenous, emanating from external sources such as the legal system, third-party payers, and peer review organizations. In rare instances, there appears to be a threat from within, when the psychiatrist (or nonpsychiatrist physician dealing with a psychiatric patient) deliberately chooses to divulge the patient's confidential communications in the absence of any clearcut legal requirement to do so (and against the express wishes of the patient). Four case examples of these unusual breaches of confidentiality are presented. The author concludes that although significant assaults on patient confidentiality are occurring from without, it is quite rare for such violations to come from within the profession itself.