Preventing Tragedy: Balancing Physicians’ Ethical Obligations to Patients and the Public Emily E. Anderson, PhD, MPH, Lee J. Black, JD, LLM, and Nathan A. Bostick, MA, MPP ABSTRACT The recent shootings at Virginia Polytechnic Institute and State University (Virginia Tech) suggest that an increased reliance upon the medical community to support public health violence prevention efforts may be warranted. As physicians are called upon to support these efforts, they must effectively balance their obligations to promote public safety with their traditional obligations to promote the best interests of their individual patients. To meet these concurrent ethical obligations, physicians’ participation in public health violence prevention should seek to improve public safety without compromising the care of patients or exposing individuals to undue harm. Physicians should, therefore, report to the appropriate authorities those patients who are at risk of committing violent acts toward the public, but should only disclose the minimal amount of information that is necessary to protect the public. Moreover, physicians should also recommend the separation of violent individuals from the community at large when necessary to improve public safety while advocating for the provision of appropriate treatment measures to improve the patients’ well-being. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S38–S42) Key Words: physicians’ ethical obligations, patient confidentiality, public health violence prevention, individual rights O n April 16, 2007 Virginia Polytechnic Insti- tute and State University (Virginia Tech) student Seung-Hui Cho killed 32 people and wounded more than 20 others before committing suicide in the deadliest campus shooting in US his- tory. In response to this tragedy, university adminis- trators and violence prevention experts across the country are examining the details to prevent future incidents. At the center of discussions is Cho’s his- tory of mental health problems. According to court papers, Cho was found to be “mentally ill and in need of hospitalization” in December 2005. Involuntary outpatient mental health treatment was subsequently mandated, but it remains unclear whether Cho com- pleted treatment or received any specific diagnosis. 1 Questions have emerged regarding the extent of the university administration’s knowledge of Cho’s men- tal health status and violent tendencies and whether this information, if available, should have prompted any action to protect students and faculty. Contro- versy also surrounds Cho’s purchase of 2 semiauto- matic pistols despite federal laws designed to prevent those judged mentally ill by the courts from purchas- ing handguns. Several days after the shootings, the Independent Virginia Tech Incident Review Panel was convened by Virginia governor Timothy M. Kaine to investi- gate Cho’s background, including his medical history; the events and circumstances surrounding the shoot- ings; and the university’s response with the purpose of understanding causes and preventing future inci- dents. 2 The panel’s focus is on warning signs as well as administrative barriers, policies, or laws that may have kept school administrators from knowing criti- cal information about Cho that could have prevented the shootings. Kaine said he would press lawmakers for reforms “if the panel found that state or federal privacy laws covering medical records need to be changed to give school administrators more informa- tion about troubled students.” 3 Similarly, in a state- ment to the panel, Virginia Tech president Charles W. Steger said, “We need to know if privacy laws can or should change so that school administrators, court officials, or the mental health profession itself has the information it needs to treat and handle those with mental illnesses on college campuses.” 4 Presently, individual medical records, including men- tal health records, are legally protected and cannot be released to third parties without patient permission except in limited circumstances, as provided in fed- eral and state privacy laws. These privacy protections apply even to deceased patients. Therefore, the pan- el’s access to Cho’s medical records is limited, al- though Cho’s family may choose to release any infor- mation to which it has access. Kaine’s and Steger’s comments draw attention to the inherent tension FOCUS Special S38 Disaster Medicine and Public Health Preparedness VOL. 1/SUPPL. 1