Confidentiality and secret-keeping on an inpatient unit

In the book Lying, Bok (1979) observes that "difficult choices arise for all those who have promised to keep secret what they have learned from a client or a patient." She asks if there are "limits to this duty of secrecy" (p. 156). As a result of the Tarasoff decision (1976), requiring therapists to take actions that may include warning potential victims in order to protect society from dangerous patients, there has been an active reexamination of what these limits should be for psychiatrists. The psychiatric literature on confidentiality, like Bok's discussion, has been concerned primarily with the individual doctor-patient relationship. There are, however, unique clinical and moral problems concerning confidentiality that arise in the specific setting of a psychiatric inpatient unit. The need for staff members to shift back and forth between work with an individual and work with a group creates particular tensions around private communications. I hope to clarify the nature of these tensions through a discussion of one inpatient unit's struggles to define appropriate limits to medical confidentiality in a hospital setting.