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I'm pleased that Dr Probst has noticed that there are difficult confidentiality issues in medico-legal work. I am dismayed, however, that he regards my article as entertaining. It would of course be quite wrong to publish such an article in that spirit. The paper briefly alludes to some appalling, harrowing tragedies involving death and injury. The purposes of the article are: (i) to draw attention to the fact that in medico-legal work providing proper care to a dangerous patient in the middle of a well publicized incident may be very difficult and becomes worse as the publicity increases; (ii) to demonstrate that, even although serious offenders are subject to severe condemnation, it is possible to use the laws in Britain to help them.
Like Dr Probst I had some concerns about publishing the patients' names, but discussed it with colleagues and with the Editor before doing so. The material and discussion used in the article arose from a meeting at the Royal Society of Medicine in which many aspects of the medical response to disasters such as the Brixton and Soho bombings were discussed. I was asked to bring my main points to the attention of a wider audience by publication in the Society's Journal. In high-profile cases of this kind every detail of the patient's life and mental state is made available for lurid interest, first in national newspapers, later in books written by journalists. The patient is not allowed to keep any significant confidences. For example, several books have been written about the Sutcliffe trial (e.g. Voices from an Evil God, B Jones, Blake Hardbacks, 1992) and so far one about the Copeland trial (Mr Evil, G McLagan & N Lowles, John Blake Publishing, 2000). None of my brief medical comments reveal any confidences; they serve as reminders to people who are familiar with this material and as indicators of the nature of the problem being dealt with. All the patient material used in the article is available in the public record. It seemed to me that it would have been artificial in these circumstances to have withheld the patients' names.
One of the several issues highlighted is the problem of assisting a patient and his devastated family in a context where usual medical considerations such as confidences are driven into the background. Psychiatrists are aware that confidentiality is an important aspect of care where it can be maintained. It is, however, possible to work for a patient's best interests even in the face of total loss of confidentiality and understandably severe public hostility.
The Royal College of Psychiatrists is currently grappling with the possibility that the mental health bill due to be published in May 2002 may include new duties of disclosure to police and others in respect of offender and potential offender patients. We are doing our best to explain how this proposal would not be in the interests of either patients or public. Confidentiality is a complicated matter in forensic psychiatry but I believe we have a good record in protecting both patients and the public.