The 1976 case of Tarasoff vs. Regents of the University of California was a landmark case in both psychiatry and in the legal profession. The case centered around the belief that mental health professionals have a burden of responsibility to the community to prevent crimes and violence against other people if they become aware that one of their patients is a possible danger. Originally, the case was decided with the mandate that mental health professionals warn anyone whom is explicitly threatened by a patient in their care. In 1976, the case was retried in front of the California Supreme Court and it was decided that the responsibility of psychiatrists extended to the notification of authorities and possibly taking additional steps to fulfill a “duty to protect.”
The case against the Regents of the University was made by the parents of a female student named Tatiana Tarasoff. Tatiana met an Indian exchange student, Prosenjit Poddar, during a few social functions at the International House on campus. The two students kissed at a New Year’s Eve Party, an act that was misinterpreted by Poddar. Poddar believed that the kiss signified the two students were in some kind of committed relationship, but this illusion was dispelled by Tarasoff who informed Poddar that she was seeing other men and saw their relationship as purely casual.
Poddar became very emotionally unstable, stalking Tarasoff and recording their conversations in an attempt to ascertain why she had turned him down. He was frequently seen around campus talking to himself and experiencing frightening symptoms indicative of a severe lapse in mental health. Poddar began to see a University psychologist, Dr. Moore, at the bequest of a friend. He confided in the psychologist that he had an intention to kill Tarasoff upon her return from a study abroad trip to South America. Dr. Moore asked for the campus police to detain the unstable student, additionally asking for him to be civilly committed as a dangerous person. Poddar was detained but released soon afterwards, as Dr. Moore’s supervisor determined he appeared sane.
In October 27 of 1969, Tarasoff went through with his plan to murder Poddar. He stabbed her to death after she had returned from her study abroad trip, prompting a lawsuit by the family against the employees of the University that had been warned of Poddar’s potential danger. The case was decided in favor of the plaintiff, the California Supreme Court held that the mental health profession had a duty to maintain client confidentiality except in cases where it could lead to the deaths or injuries of directly threatened individuals. The majority opinion, written by Justice Tobriner, held that “When a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. The discharge of this duty may require the therapist to take one or more of various steps, depending upon the nature of the case. Thus it may call for him to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances.” This decision by the California Supreme Court was a landmark decision, and it has been cited as precedent in cases as varied as the Virginia Tech shooting and the D.C. Sniper Case.
The reasoning of the majority was that the psychiatrists in question had not done their duty to the community by with-holding information on a student that posed a clear and present danger to the campus and a specific individual. Previous similar cases had relied on the idea of client-psychiatrist privilege to protect the psychiatrist from liability and the client from the disclosure of their threats. In the majority opinion, the court concluded that they did not expect the psychiatric community to perfectly predict the violent tendencies of patients, merely to make a reasonable effort at notifying individuals when a patient undergoing treatment mentioned a plan to do them harm. According to the majority opinion, psychiatrists would not be held to a “perfect standard,” they were expected “only to exercise that reasonable degree of skilled care ordinarily possessed by members of their profession under similar circumstances.”
The majority opinion cited as precedent the reasonable expectation that public health professionals and doctors notify the persons that a contagious individual with a major disease has come in contact with. While patients to medical doctors have privacy and confidentiality between them and their doctor, this does not necessarily extend to cases of public health. If a patient is diagnosed with an STD or with a major contagious disease, it is the duty of the doctor to make sure that past contacts are notified and that the public at large is protected if necessary. In this way, the doctor is able to violate confidentiality in cases where public safety is threatened. According to the case, “The protective privilege ends where the public peril begins.”
The Tarasoff case in 1974, the one that was later superseded by the Supreme Court ruling, established a responsibility to warn rather than a responsibility to protect. The Supreme Court decided that there were ways the psychiatrists could act to protect the community other than just warning the victim (such as involving police) and that the involvement of police was not always the best option.
The considerations in the decision of the court were complex. The defendant was found to have violated his professional duty, as there was a present and foreseeable risk that the patient would carry out his plan to murder Tarasoff. Forseeability had previously been established in Rodriguez v. Bethlehem Steel Corp, and according to the majority opinion, the “defendant owes a duty of [17 Cal.3d 435] care to all persons who are foreseeably endangered by his conduct, with respect to all risks which make the conduct unreasonably dangerous.” The idea of a duty to protect does not extend to the general population, but only to a group of individuals that have a special relationship with the person in question that places them in a care taking role for the patient and for the third parties that could be endangered through the patient’s actions. A duty of care is certainly present in the case of a psychiatrist, as they are privy to information which is not shared with the general public. The duty of care extends to the people that are threatened in the presence of the psychiatrist; they are placed in a position where they are the caretakers of the threatened person as well.
Also cited in the decision of the court was the case of Merchants Nat. Bank & Trust Co. of Fargo v. United States which was particularly of interest because it also dealt with a mentally unstable person who later murdered someone. The Veterans Association was held liable for a murder that a man committed on a farm that he was employed on, because the Veterans Administration had done nothing to warn the farm of the man’s mental issues and history of violence.
The Defendant Therapists were not able to escape liability solely because they did not have Tatiana as one of their patients. The Burden of Care, previously extended in the psychiatric profession only to patients undergoing treatment, was extended to the public at large. The Burden of care was transferred onto the therapist at the time that there professional judgment, in accordance with the standards of their profession, gave them a reasonable degree of suspicion that someone in the community was in danger of physical harm from a patient under their care. Incurring this obligation required the therapist to take a few steps, depending on the level of danger the patient represented. The therapist could warn the police, the intended victim, or others who could then pass the information along. In addition, the therapist had a responsibility beyond the responsibility to warn that included doing anything reasonable to protect the intended victim dependent on the unique circumstances of the case. The plaintiff believed that Tatiana’s death occurred because nothing was done to warn her or anyone else of the danger posed by the killer, and that the duty to protect was implied in the profession of psychiatry. The defendants maintained that they were not required to protect Tatiana or to warn her, because their professional positions required them to act for the benefit of their patients even at the expense of the community.
The balance of patient confidentiality and the duties of the psychiatrist is weighed within the court opinion, according to Tobriner, “There is no privilege … if the psychotherapist has reasonable cause to believe that the patient is in such mental or emotional condition as to be dangerous to himself or to the person or property of another and that disclosure of the communication is necessary to prevent the threatened danger.” The majority opinion held that the responsibility towards confidentiality had been previously explored in legislative cases where confidentiality had been found to have limits. Additionally, they posited that the duty of confidentiality was on the same plane, and did not supersede, the professional duty of the psychiatrist towards the public.
Despite finding the therapists guilty of failing to warn the victim about the danger posed by Poddard, the court released the defendant therapists from any culpability in their failure to detain Poddard. The defendants contended that the Government Code section 856 released them from liability as it could be interpreted as giving a broad immunity to government employees and to therapists for injuries committed by individuals that they do not confine when given power to do so. The court found that Dr. Moore had a reasonable responsibility to argue against his superior when he made the decision not to confine the patient. According to the court, “Section 856 also insulates Dr. Moore for his conduct respecting confinement, although the analysis in his case is a bit more subtle. Clearly, Moore’s decision that Poddar be confined was not a proximate cause of Tatiana’s death, for indeed if Moore’s efforts to bring about Poddar’s confinement had been successful, Tatiana might still be alive today. Rather, any confinement claim against Moore must rest upon Moore’s failure to overcome Powelson’s decision and actions opposing confinement.” Under that reasoning, the plaintiffs were allowed to allege Dr. Moore’s liability, but that liability was thrown out under the previously mentioned Government Code section 856.
Similarly, the Court found that the police could not be held responsible for their failure to detain the mentally ill assailant, as the police were following the strict regulations set forth in the Welfare and Institutions Code. The police could not be held criminally liable for the actions of any patient released after the 72-hour treatment and evaluation period afforded to suspected community risks.
The dissenting opinion was split into two parts. Mosk wrote a concurring and dissenting opinion in which he disagreed with the findings of the court on only a few principles. He wrote that, “I cannot concur, however, in the majority’s rule that a therapist may be held liable for failing to predict his patient’s tendency to violence if other practitioners, pursuant to the “standards of the profession,” would have done so” citing the case of People vs. Burnick as a precedent that established the inherent unreliability of the psychiatric profession and the lack of any real body of professional standards. This case contained a great deal of supporting literature that included several documents questioning the ability of the psychiatric profession to self-regulate, and questioning the ability of psychiatrists to correctly diagnose mental illness in the first place. The court during People vs. Burnick ended up finding that psychiatrists were not “uniquely qualified” to issue predictions of dangerous behavior, as there was no clear consensus in the profession as to what constituted dangerous behavior or warning signs.
Clark wrote an additional and separate dissenting opinion, essentially arguing that undermining the ability for the psychiatrist to assure his patient of confidentiality would make it more difficult for him/her to establish the trust and rapport necessary to conduct psychiatric evaluation in the first place. Clark believed that while the duty to protect may be guided by good intentions, it would endanger the community by preventing mentally ill people from seeking treatment with the belief that they would be exposed for their mental illnesses to their neighbors and their friends. According to Clark, “Given the importance of confidentiality to the practice of psychiatry, it becomes clear the duty to warn imposed by the majority will cripple the use and effectiveness of psychiatry. Many people, potentially violent — yet susceptible to treatment — will be deterred from seeking it; those seeking it will be inhibited from making revelations necessary to effective treatment; and, forcing the psychiatrist to violate the patient’s trust will destroy the interpersonal relationship by which treatment is effected.”
The findings of the court will have very negative and adverse consequences for the treatment of the mentally ill. Supposedly dangerous people who are forced into treatment are already relegated into the margins of society, the only thing keeping them from feeling completely alienated from the public is their belief that their problems have some degree of confidentiality. Confidentiality gives the patient hope that after their treatment they can seek normal life in a public that is unaware of their previous struggles with mental illness. The California Supreme Court acts to protect the public, but in doing so it weakens the psychiatric establishment and directly interferes in its ability to treat patients and to conduct business. Without the assurance of confidentiality, patients will not seek treatment at the same rates. The Court is creating a dangerous environment both for the public and for the mentally ill individuals who refuse treatment. A brief survey of academic literature for medical professionals shows a variety of opinions on the Tarasoff decision, as well as exactly how the Duty to Protect can be implemented in situations where privacy is implicit in the patient’s decision to seek treatment. The Tarasoff decision has been adopted by numerous states, and it is valid in more professions than just psychiatry. The professions of education and social work are equally burdened by the responsibility to protect the community at the expense of patient privacy.
The Tarasoff decision had an impact on the treatment of potentially violent patients on a national level as well as a state level. Part of the impact of the case is what it has done to the perceptions of psychiatrists of their own responsibilities, as was found in 1986 by a American Academy of Political and Social Science Study. The study found that the increase in willingness to warn potential victims of violent crime of threats increased disproportionately in California, but it also went up nationwide. (Bowers, 1986)
The Tarasoff decision was a landmark case that dealt with confidentiality issues and professional responsibilities. The case has had a national impact, and it has since been upheld and extended to several states. The current thinking in the psychiatric community is that the patient-doctor privilege does not contain the expectation of the patient that threats will be kept private, and that issuing Tarasoff warnings does not require a waiver of that privilege.
Bowers, William. How did Tarasoff Affect Clinical Practice? Annals of the American Academy of Political and Social Science. 484. Mar. 1986. Pp 70-85
Rodriguez v. Bethlehem Steel Corp. (1974) 12 Cal.3d 382 , 399 [115 Cal.Rptr. 765, 525 P.2d 669]
Merchants Nat. Bank & Trust Co. of Fargo v. United States (D.N.D. 1967) 272 F.Supp. 409
eople v. Burnick (1975) 14 Cal.3d 306 [121 Cal.Rptr. 488, 535 P.2d 352]
Welfare and Institutions Code, fn. 25 [17 Cal.3d 450]