Your 15-year-old retention patient completed treatment 2 years ago with an excellent result. You remember him well—the youngest of 4 siblings whom you treated. When he returns for an adjustment of his upper retainer, you are taken aback by the severe retrograde wear of his darkened dentition since you last saw him 1 year ago. You notice severe inflammation in his nasal region. Although he tells you that he has developed an “awesome case of hay fever,” you suspect that he is engaging in illicit drug use. You close the door to your operatory, and, your direct inquiry confirms his cocaine habit. He pleads with you not to tell his father, who is your neighbor.

You are now faced with an ethical dilemma. Do you respect the patient’s wishes for confidentiality? If you do so, might you be considered negligent in averting potentially serious health consequences? Alternatively, do you inform his parents of his habit so that rehabilitation can begin as soon as possible?

Confidentiality is essential in the establishment of trust in a doctor-patient relationship and is an integral component of the Hippocratic oath. The oath states that “whatsoever I see or hear in the course of my profession . . . I will never divulge, holding such things to be holy secrets.” There are indeed instances when confidentiality is morally and legally violated, as in a case of suspected child abuse or a physically incompetent pilot whose uncontrolled sleep apnea places his passengers at risk. But when should confidentiality be breached in a dental setting?

Many ethicists believe that confidentiality can be overridden when there is sufficient evidence to indicate that the patient would be harmed by maintaining confidentiality. Confidentiality is viewed as a “prima facie” principle: “a duty that is morally binding unless it conflicts with a more pressing moral duty.” Confidentiality can be violated if it incurs risks to other people or to society. For example, if a violent, mentally unstable patient vows to murder a specific person, the health care provider must override confidentiality and inform the appropriate authorities. Many ethicists agree that “patient confidentiality is not an absolute rule, and privacy is not an absolute right.”

To further complicate your dilemma, your patient’s consent is held by a parent or guardian because your patient is a minor. Should a minor’s request for confidentiality be honored or overridden, especially when the consequences of maintaining confidentiality might be dire? Drug abuse is certainly detrimental to the patient and could ultimately become dangerous to others and to society.

The fact that this patient was willing to admit his illegal drug habit to you might indicate that he is receptive to addressing his problem. Your long-standing, trusting relationship with this youngster might be essential in your direct communication that he is the most appropriate person to disclose his cocaine abuse to his parents. It is unquestionably much healthier for him to initiate the resolution of his problem than it is for you to do it for him. And for you, encouraging your patient to tell his parents is a satisfying act of beneficence.

Your patient needs to know that your obligation to honor his confidentiality is important to you, but his problem is so severe that, if he refuses to tell his parents, your obligation is to inform them. Your intent and effort are designed to protect him from further self-destructive behavior and provide adequate justification for overriding confidentiality. You can then only hope that his parents will offer him unconditional support in his rehabilitation.