Ethical Challenges in the Face of a Targeted Threat

To the Editor: In this letter we describe some of the ethical challenges that emerged during an evaluation of a health care plan to assess the implementation of a disease management program for depression. In the fall of 2002, focus groups were held with enrollees of the health plan who had a diagnosis of depression with the goal of examining their experiences as health care recipients. All research protocols had been approved by the institutional review board (IRB) of the affiliated university. Before the focus groups, participants received a letter explaining the nature of the evaluation. At the start of the focus groups, consent forms were discussed, including the limits of confidentiality, and each participant signed a form. All identifying information specific to the case described here has been altered.

During one of the focus groups, a participant reported having unsuccessful surgeries, which led to complications and subsequent impairment. The participant stated during the group: "I've had times when I lay there and think about … buying a damn gun…. Just to hell with him [the doctor] …. What have I got to live for? I'm not going to prison." There was enough information to indicate that this person was at high risk of violence on the basis of motivation and other stressors. We responded to these challenges by obtaining additional consents for release of information from the participant after the conclusion of the focus group. We sought immediate clinical and legal consultation—first, for a psychiatric evaluation, and second, for information about legally permissible actions to prevent the threatened violence.

The dilemma we faced was the ethical obligation for researchers to maintain confidentiality—duty to the participant—within certain boundaries (1) and the opposing duty to protect, which required notification of the identified third party because of the targeted threat (2). Other questions emerged: Do qualitative researchers establish a "special relationship" as clinicians do (3)? And what are the ethical obligations attached to that relationship? Appelbaum and Rosenbaum (3) suggested that through face-to-face interviews researchers cultivate a rapport with participants to facilitate the receipt of sensitive information. There is no case law establishing that a special relationship exists between the research participant and the researcher as a result of qualitative inquiry.

We made an effort to protect the third party by calling the local mobile crisis team for an emergency psychiatric examination of the person who made the threat. The team determined that he was not a threat. We met our IRB and legal obligations by calling the crisis team, but was that enough? Also, what additional follow-up with the participant or his health plan would be overstepping the research boundaries?

Furthermore, we found no guidance in the literature about how to handle a Tarasoff-related situation in a focus group. Should the focus group participants be debriefed? If so, at what point during the group should this be done, and how?

This case raised compelling ethical and practical dilemmas that qualitative researchers may face. It is hoped that the case will serve as a reminder to investigators of the need to continually examine the adequacy of their research practices and protocols. In addition, we suggest that further study should be given to Tarasoff-related situations in focus groups.