Just before the bicentennial fireworks started, on July 1, 1976, the precedent-setting Tarasoff v. Regents of University of California case redefined patient confidentiality by introducing the concept of “mandated reporting” and codifying the ethical and legal “duty to warn.”
The case centered on the 1969 murder of Tatiana Tarasoff by Prosenjit Poddar, a man she briefly dated, who we might today call a stalker.
Poddar disclosed his plan to murder Tatiana to his therapist, Lawrence Moore, who practiced at the University of California, Berkeley. (I’m referring to her by her first name to distinguish Tatiana Tarasoff the person from Tarasoff the case.) Ultimately, the University of California was held responsible for failing to warn Tatiana of the imminent threat to her life.
This case defined new rules for health care provider-patient confidentiality, introducing mandated reporting for not only behavioral/psychiatric threats but also other settings, such as infectious disease during the HIV/AIDS era and, more recently, the world of genomics. The Tarasoff decision, released three days before the American Bicentennial, forever and dramatically changed the doctor-patient relationship.
Tatiana Tarasoff met Prosenjit Poddar at a folk-dance class in 1968, when he was a student at the University of California, Berkeley and she attended the nearby Merritt College. (She transferred to UC Berkeley in the fall of 1969.) The year before, Poddar had arrived in the U.S. from Bengal, India, for graduate studies in engineering.
Poddar’s arrival to the San Francisco Bay Area during the “Summer of Love” was a culture shock. He and Tatiana began to casually date, seeing each other about once a week. When Tatiana kissed Poddar, he interpreted this to mean they had a serious relationship. But during the spring of 1969, Poddar learned that it was “just a kiss” to Tatiana, who relayed to him that her feelings were casual and she was interested in dating other men.
Poddar could not accept it. He became severely and clinically depressed, and on the occasions when he saw Tatiana, he covertly tape-recorded her. At the urging of friends, Poddar sought psychiatric treatment at Cowell Memorial Hospital, affiliated with UC Berkeley, on June 5, 1969, with psychologist Lawrence Moore.
During that summer — against the backdrop of Apollo 11, Woodstock, and more eerily, the Manson murders — Tatiana had gone to Brazil for vacation. Meanwhile, in his seventh session with Moore, on Aug. 20, 1969, Poddar disclosed to Moore his desire and plan to harm and potentially murder Tatiana when she returned home.
Moore was alarmed by the disclosure and wrote a letter to the campus police chief that he believed Poddar suffered from a “paranoid schizophrenic reaction.” Moore wanted the campus police to place Poddar on a 72-hour hold. However, when the campus police briefly detained Poddar, they found him rational and released him after he promised to stay away from Tatiana.
Although Moore’s supervisors concurred with his opinion of a 72-hour hold, the director of psychiatry at Cowell Memorial Hospital, Harvey Powelson, overruled it because he did not think Poddar’s behavior was alarming enough to breach confidentiality. Powelson asked the police chief to return Moore’s letter and instructed Moore to destroy all copies of the letter and his clinic notes. Powelson further told the staff not to pursue any subsequent attempts to involuntarily hold Poddar. Nobody warned Tatiana or her parents about Poddar’s plans.
On Oct. 27, 1969, Poddar went to Tatiana’s home during the day and tried to see her, but her mother told him she wasn’t home. He returned that night to find Tatiana alone in her house. When she wouldn’t talk to him, and he wouldn’t leave, she screamed. Poddar shot her with a pellet gun. She ran outside to get away, and Poddar chased her outside her house and stabbed her with a butcher knife 17 times until she died.
Poddar then called the police himself and confessed to the murder and asked that they come and handcuff him. Poddar initially pled insanity in a case that became complicated. He was initially arraigned and charged with first-degree murder, but at trial, was convicted of second-degree murder after he testified to having diminished capacity. He served only a five-year sentence; upon appeal, the charge was reduced to manslaughter, and he was released from his sentence after four years on the condition that he self-deport back to India, which he did.
While Poddar’s case was still going through the appeal, Tatiana’s parents sued the University of California for failure to detain him and failure to warn them about the potential danger. They also sought damages for Powelson’s actions, which they viewed as a breach of duty to the patient and public.
Their lawsuit was initially dismissed in the lower court, but upon appeal, the California Supreme Court overturned the dismissal and held that indeed, the defendants had a “duty to warn.” Unique to this case were two separate decisions from the California Supreme Court in 1974 and 1976.
What is known as the final Tarasoff decision is based on a rehearing in 1976 in which the Supreme Court provided greater qualifications surrounding health care providers’ “duty to warn” and “duty to protect.” The rehearing was based on the strong outcry and reaction from the psychiatry community, which was reported on in the Jan. 22, 1975, issue of Time magazine: “Warnings to save a life have long been allowed by accepted medical ethics, but never legally required.”
Here are some key excerpts from the final 1976 Tarasoff decision:
Psychiatrists were held to the same standard as any other medical practitioner:
“The role of the psychiatrist, who is indeed a practitioner of medicine … the judgment of the therapist in diagnosing emotional disorders and in predicting whether a patient presents a serious danger of violence is comparable to the judgment which doctors and professionals must regularly render under accepted rules of responsibility.”
Regarding the failure to warn third parties: “In the instant case … defendant therapists did in fact predict that Poddar would kill but were negligent in failing to warn.” (Italics mine.)
On the limits of patient confidentiality, Tarasoff cites the 1957 American Medical Association code of medical ethics but then opines:
“We conclude that the public policy favoring protection of the confidential character of patient-psychotherapist communications must yield to the extent to which disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins.”
What was game-changing about Tarasoff is that it not only established limits to confidentiality, stating it ended where public peril begins, but also established a duty to warn third parties when harm is “foreseeable” and “imminent.”
The precedent set by Tarasoff in the behavioral health setting led to mandated reporting by any health care provider in any setting when patients make threatening statements about potential harm to themselves or others or are agents of harm.
For example, therapists now disclose to patients that they are required to report to the police any threats patients make. This also extends to physiological conditions creating public menace; for instance, noncompliant patients with very poorly controlled diabetes are a public menace if driving, and practitioners could be liable for “failure to warn” if they don’t report their concerns about known roadway menaces to the department of motor vehicles. Mandated reporting laws vary in different states.
Tarasoff also expanded on case law in the infectious disease setting established in famous cases such as Jacobson v. Massachusetts (1905), which empowered the public health authority to limit individual freedom when a patient’s contagious disease is a threat to public health. It also expands on Hofmann v. Blackmon (1970), which recognized a duty to advise and warn members of the patient’s family about a contagious disease.
In the early years of HIV/AIDS, social stigma and lack of treatment prevented voluntary anonymous testing, while health care providers failed to warn patients in need of transfusions that the public blood supply continued to be unscreened, with the risk of transfusion AIDS. The Institute of Medicine in 1995 stated: “The early history of HIV/AIDS (1981-91) reflects a failure of individual healthcare bureaucrats to provide moral leadership, which had devastating consequences for public health.”
When the duty to warn in the HIV/AIDS context was recognized based on the Tarasoff decision, it led to partner notification programs in various states, which continues today. After 1996, when the protease inhibitors were developed, the duty to warn continued to be an important standard when HIV status became more clinically covert. Tarasoff also led to contagion notification standards in the Covid era.
The “duty to warn” in the genetic context was established in several health law cases including Pate v. Threlkel (1995), a case involving an autosomal dominant case of inherited medullary thyroid cancer, in which the courts found that a doctor failed to warn the patient that because it was inherited, her children were at risk. (I discuss this case here and expand on pediatric medullary thyroid cancer when warnings are ignored by adult probands who refuse to screen their children.)
The Pate ruling reads in part: “Physicians may owe a legal duty to the children of a patient if the children are identified beneficiaries of the prevailing standard of care … when the prevailing standard of care creates a duty that is obviously for the benefit of certain identified third parties and the physician knows of the existence of those third parties, then the physician’s duty runs to those third parties. Duty to warn satisfied by warning the patient.”
Similarly, in Safer v. Estate of Pack (1996), the adult daughter was not warned that she could suffer the same fate as her father, who died in his mid-40s from genetically inherited colon cancer. In this case, the courts ruled that limiting the warning to the patient was not enough; physicians also had a duty to warn the patient’s at-risk family members. From the decision: “We see no impediment, legal or otherwise, to recognizing a physician’s duty to warn those known to be at risk of avoidable harm from a genetically transmissible condition. In terms of foreseeability especially, there is no essential difference between the type of genetic threat at issue here and the menace of infection, contagion or a threat of physical harm.”
Criteria were proposed in a 2000 issue of the American Journal of Medicine about when to warn of genetic risks in cases where affected patients are reluctant to share their information with at-risk relatives. Issues such as autosomal dominance, acceptable prophylactic treatment, and penetrance are all considerations, including whether the disease is adult-onset in pediatric contexts. The American Society of Human Genetics published guidelines in 2013 for the mandatory return of results in genetic screening.
As for the Health Insurance Portability and Accountability Act (HIPAA), which defines protected health information and conditions for health information disclosure, it always permitted Tarasoff exceptions to confidentiality when “in the exercise of professional judgment, [a physician] believes the disclosure is necessary to prevent serious harm to the individual or other potential victims. …”
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Fifty years later, the murder of Tatiana Tarasoff and her relationship with Poddar is still haunting. Tatiana’s and Poddar’s fateful romance was the subject of a 1986 true crime nonfiction work by author Deborah Blum, who was also a student at UC Berkeley in 1969.
The Tarasoff case remains a pivotal marker in bioethics at the bicentennial as we now reach the country’s 250th birthday. Though a controversial decision at the time, it established important ethical duties for health care providers, while enabling countless third parties to reduce their risks of potential harm.
M. Sara Rosenthal, Ph.D., is professor and founding director of the University of Kentucky Program for Bioethics and Oncology Ethics Program and chair of the U.K. Healthcare Ethics Committee.
