A covenant of confidentiality characterizes physician-patient relationships. But suppose that during a routine medical examination, a prison physician notices that Prisoner A has drugs and paraphernalia. Should the physician report the crime or should confidentiality prevail?

Professional communications between physicians and patients are statutorily protected as confidential. Health professionals have an interest in maintaining confidentiality so patients feel comfortable revealing personal but necessary information. Prisoners do not possess full constitutional rights to privacy but generally retain them in the physician-patient relationship. In fact, respect for confidentiality is particularly important in a prison hospital setting, where patients feel distrust because physicians are often employed by the incarcerating institution. Even then, physicians’ first responsibility is to their patients. Circumstances in which to give privileged information to authorities remains the physician’s decision.

The right to privacy supersedes a duty to report the drugs and paraphernalia as there is no imminent threat to others. In contrast, a weapon harbored by a prisoner represents an imminent threat to others. Thus, upon discovering a sequestered weapon during a routine examination, the physician has a “duty to warn.”

The possibility of discovering contraband reinforces the need for informed consent at several stages. First, patients should be evaluated and treated only after they provide informed consent, unless they are incompetent. Before an X-ray is taken, they should be informed that it can demonstrate metal and other foreign bodies, and their agreement to the procedure obtained. Second, if a weapon is discovered, the patient should be given the opportunity to surrender it to authorities. And if Prisoner A is harboring drugs and a needle, it is the physician’s responsibility to educate about the potential harm of drug use.

— Adapted from “Cases in Bioethics: Selections From the Hastings Center Report,” 1989