Lateral Violence in Healthcare: Policy, Duty, and Risk Prevention

Introduction: Tarasoff and the Duty to Warn

This research proposal examines lateral violence in U.S. healthcare institutions through the scope of policy formation as it pertains to medical malpractice and organizational behavior. In recent years, investigations into lateral violence (LV) in the practice setting have become increasingly important as professional liability and the concept of "duty" in patient care have come under close scrutiny.

In Tarasoff v. The Regents of the University of California [S.F. No. 23042, Supreme Court of California, July 1, 1976], a wrongful death action was filed against the Regents of the University of California, alleging that psychotherapists at a university hospital and campus police officers had failed to respond adequately to a patient's stated intention to commit murder. Specifically, the charges alleged that patient Prosenjit Poddar had confided homicidal ideation toward victim Tatiana Tarasoff to Dr. Lawrence Moore, a psychologist employed by the Cowell Memorial Hospital at the University of California at Berkeley. At Moore's request, campus police briefly detained Poddar but released him after a cursory assessment. The plaintiffs further charged that Dr. Harvey Powelson, Moore's superior, also took no further action to follow up on the threat. Poddar subsequently murdered Tatiana Tarasoff in October 1969.

In the initial trial court decision, the defendants' demurrers to the complaint were sustained without leave to amend, and judgment was entered in favor of the defendants. On appeal, the California Supreme Court affirmed the judgment in favor of the police officers but reversed the earlier decision in favor of the therapists and the Regents. The reversed decision held that the plaintiffs could amend their complaints to state a cause of action against the defendants based on the threat of imminent danger to a third party who had been put in serious peril. The court maintained that professional duty to a standard of reasonable care should have compelled the defendants to take protective action and that they had nevertheless failed to exercise a reasonable response toward protecting a third party threatened with intentional harm.

In this landmark negligence ruling, the court held that when a therapist determines — or is forced to confront an ethical dilemma arising from — a patient's express intent to cause serious harm or danger of violence to another person, the therapist incurs an obligation to exercise fair warning within the scope of "duty" defined by reasonable care. The case was instrumental in further defining the obligation to warn, establishing that such a duty was not a discretionary act protected under the immunity provisions of California Government Code § 820.2. The judicial reinterpretation that reversed the original decision cited a breach of duty in the failure to communicate danger, while also holding that defendants were insulated from substantial liability under Government Code § 856. The decision further redefined nondisclosure (§ 5328) as a measure for ensuring greater safety where healthcare organizations are involved. The policy definition of the case is articulated in the Healing Arts and Institutions § 30, "Medical Practitioners and Duty of Therapist to Dangerous Patient's Intended Victim," which sets standards for professional conduct, including appropriate disclosure where serious danger of violence to another person may be present.

This research proposal advances that topic and examines the general field of duty to disclosure as it applies to healthcare practitioners. Of key importance to the outcomes of the 1976 ruling is the recent trend in best-practices policy recommendations directed at risk mitigation of violence in healthcare settings. If Tarasoff set the pace for future decisions on patient consent and disclosure where imminent danger may be present, the expansion of the topic over the last thirty years now permeates the clinical practice setting. In keeping with contemporary interest in violence as a pronounced dimension of healthcare policy, this study turns the disclosure issue toward questions of ethical obligation where peer-to-peer or lateral violence is present, and toward the substantial work that healthcare administrators, policymakers, and practitioners are undertaking to ensure that "duty" is adequately addressed.