Confidentiality and the Duty to Warn: MCCQE Notes

The rule

Health information is confidential. Disclosure requires the patient's consent, and disclosure within the circle of care for the purpose of treatment is implied.

Mandatory disclosure — you must

You have no discretion here, and the patient's objection does not change it:

• Reportable communicable diseases to public health (the list is provincial; it always includes tuberculosis, syphilis, HIV, measles, meningococcal disease)
• Suspected child abuse or neglect to child protection services. This is a duty on any person, is based on reasonable suspicion rather than proof, and overrides confidentiality entirely
• Fitness to drive, where provincially mandated — uncontrolled seizures, syncope, significant visual field loss, dementia affecting driving. Mandatory in most provinces, discretionary in a few (Alberta, Quebec, Nova Scotia)
• Fitness to fly or operate a train/vessel to the relevant federal authority
• Gunshot and, in some provinces, stab wounds to police
• Court orders, subpoenas and coroner's investigations

Discretionary disclosure — you may

The duty to warn (from Smith v. Jones in Canada, Tarasoff in the US) permits breaching confidentiality when three conditions are all met:

1. A clear and identifiable person or group is at risk
2. The risk is of serious bodily harm or death
3. The danger is imminent

Disclose the minimum necessary, to the person at risk and/or police. A vague threat against no one in particular does not meet the test.

What is not an exception

• Family asking about the patient. No, without consent — including a spouse.
• A capable patient's refusal to tell their partner about an STI. Counsel and support disclosure, offer to facilitate it, involve public health for partner notification (which is done anonymously). Do not disclose directly on your own initiative as a first step.
• Employers or insurers. Only with explicit written consent.

Practical sequence for the exam

When a stem sets up a conflict, work through it in order:

1. Is this on the mandatory list? → report, and tell the patient you are doing so
2. Does it meet all three duty to warn criteria? → disclose the minimum, to the person at risk
3. Neither? → seek the patient's consent, address their reasons for refusing, and involve public health where the mechanism exists

Telling the patient what you are about to disclose, and why, is almost always part of the right answer.