Case 2a. Leedy v Hartnett (1981) details a veteran with schizophrenia and a history of impulsive violence and chronic alcohol(Drug information on alcohol)ism who assaulted friends with whom he was staying after an evening of drinking with them. The friends sued, claiming the VA had breached the duty to protect them. The court said the violence was not foreseeable because the patient had never previously assaulted drinking friends. A history of violence was not enough to establish foreseeability, and the court ordered summary judgment for the defendants.
Case 2b. Bardoni v Kim (1986) concerned a man in outpatient treatment for chronic paranoid schizophrenia who developed the delusions that his wife was poisoning him and dating his brother; that the brother had given him a hernia; and that his blood was being poisoned either by his former employer or by air pollution. He had no history of violence. He told his wife he was thinking of killing his brother, but she did not take him seriously and never told the treating psychiatrist. The patient later killed his mother and brother and assaulted his wife.
The survivors sued the psychiatrist, alleging a failure in the duty to warn. The court issued summary judgment for the defendant as it related to the representatives of the patient's mother, stating that the violence was not foreseeable because the patient had never threatened his mother or wife. In regard to the brother, the court held that the psychiatrist should have known that the patient posed a serious threat sufficient to defeat a summary judgment motion.
Case 2c. A psychiatrist evaluated a man with chronic schizophrenia, spending all of five minutes with the patient and failing to review past records that showed a history of substance abuse, violence and noncompliance with medication (Hamman v County of Maricopa, 1989). Beyond that, the facts are in dispute. The parents alleged that they told the doctor that their son carried around pictures of decapitated animals; that they feared their son was a lethal threat; and that they never turned their backs on him. They further alleged that they begged the doctor to hospitalize their son, but that the doctor told them that their son was harmless.
In any case, the doctor sent the son home with a prescription that the son refused to take. Two days later, without provocation, he severely beat his stepfather, causing brain damage and precipitating a myocardial infarction. The parents sued, alleging breach of the duty to protect. On appeal to Arizona's Supreme Court, the court held that there was a duty to protect in this case and that the plaintiffs were foreseeable victims. The court sent the case back to the lower court for trial.
This case is unusual in that the court found a duty and potential liability. In other duty-to-protect cases, e.g., Jablonski v United States of America (1983), courts have found liability when defendants failed to review records. In addition, the facts in Hamman are consistent with a psychiatric evaluation that was below the standard of care (For an additional case, visit <www.psychiatrictimes.com/violence.html>--Ed.).Affective Disorders
Case 3a. A woman who had suffered from major depression shot and killed her husband while he slept. She had previously taken out a restraining order, fearing her husband would harm her and their children. In the past, she had verbally threatened other relatives, as well as her husband.
The decedent's estate administrator sued the wife's psychiatrist in Eckhardt v Kirts (1989), alleging failure of duty to protect. The court granted summary judgment for the defendant, holding that under Illinois law, the duty to warn requires a specific threat to a specific victim. Nonspecific threats against the victim and other family members were not sufficient to trigger the legal duty.
Case 3b. Sellers v United States (1989) involved a veteran with bipolar disorder who--during one hospitalization--threatened a student nurse with death, was generally argumentative and had been in one minor altercation. Two months after discharge, he visited his girlfriend. Her former boyfriend was present but, according to a witness, was not provocative in any way. The veteran beat the former boyfriend with a baseball bat. The court held that the victim was not identifiable and that the defendants had no duty to protect the public at large. The court found for the defendants.Organic Brain Syndromes
Case 4a. Webb v Jarvis et al. (1991) detailed a primary care physician who prescribed anabolic steroids to a man who then threatened his wife with a knife and a gun. She fled but later returned home with a deputy sheriff. The patient shot the deputy and then drove to the hospital where he shot and killed a nurse. The plaintiffs sued Orville Lynn Webb, M.D., alleging he overprescribed medication, causing a toxic psychosis and the resulting violence. The court issued summary judgment for Webb, holding that: a) overprescribing did not create a risk the patient would shoot someone; and b) the victims were not identified or otherwise foreseeable.
Case 4b. Boulanger v Pol (1995) was brought after a young man with a posttraumatic organic brain syndrome shot his uncle, who the patient believed was Satan. The young man had been previously hospitalized and had a history of assaults on his uncle and his father and attempts of self-harm. After one discharge from the hospital, he lived peacefully in a community residence and never referred to his uncle as Satan. While visiting his parents when his uncle happened to be present, the patient took a shotgun that was in the home and shot the uncle. The uncle sued, claiming negligent release and failure to warn. The court said the release of a voluntary patient did not trigger a duty to protect and that since the uncle knew the nephew thought he was Satan, there was no duty to warn. The court found for the defense.Concluding Thoughts
These cases illustrate that courts are reluctant to hold physicians and institutions liable for impulsive violence that appears not to be foreseeable. When physicians have practiced reasonably under applicable state law, they are not found to be negligent when a bad outcome occurs.
Thus, the clinical, legal and ethical mandates prove to be identical: to carefully exercise one's best clinical judgment. When the clinician does so, no negative legal consequences are likely to follow, and the clinician is fulfilling their ethical duty.