Gautam Gulati, Colum P Dunne, David J Meagher and Brendan D Kelly consider what measures need to be in place to protect both doctors and patients when death threats are directed towards doctors.
Death threats directed towards doctors lead to clinically and ethically complex situations which require a considered response to ensure the safety of the practitioner and the wellbeing of patients.
Death threats by patients towards doctors are not rare. Psychiatrists are especially vulnerable as are emergency medicine physicians and family doctors.1 One survey of psychiatrists revealed that 28% had received death threats.2 Doctors working in specific areas such as abortion clinics may also face particular risks.3
Death threats represent a form of violence aimed at striking fear into the intended victim and may be a precursor of future serious harm. It is not clear how commonly death threats are followed by homicide. The limited evidence to date suggests that the risk is low, but, given the gravity of homicide and the likelihood of other negative consequences resulting from threats, greater clarity is needed.4,5
Most threats fall under two categories: situational and transferential . Situational threats occur “in the heat of the moment” and are made in situations such as discharge from care or the setting of boundaries in respect of prescription of drugs with dependence risks (e.g. benzodiazepines). Such threats typically resolve without adverse consequence and the risk of physical violence, although acute at the time, reduces subsequently. Transferential threats, on the other hand, arise from the nature of the doctor-patient therapeutic relationship, can develop over time, and may be communicated through a third party. These have a higher risk of remaining unresolved and being disruptive to the life of the doctor.6
Adverse outcomes both for the perpetrator and victim of a death threat are common. Poor mental health, violent victimisation and suicide are reported in studies of perpetrators7,8 while anxiety, loss of confidence, difficulties in social and family life, and self-blame are common in victims3,9 alongside the risk of violent victimisation.
Death threats against doctors are under-reported. It is not clear why this is the case. Physicians as a cohort may be less fearful of death than non-physicians9 or may be hesitant to report violence because they believe they provoked the attack. Some may feel ashamed or think it is “part of the job” to deal with violent patients.10
It is not known what may prevent such threats. Professionally, the setting of therapeutic boundaries before consultation, during treatment and after discharge is of value for many reasons probably including reducing risk of threat. Displays of departmental policies against aggression such as the Zero Tolerance policy in the UK National Health Services11 may act as a deterrent. It seems reasonable that doctors who are aware of potential occupational risks exercise caution in their use of social media and patient-physician boundaries.12
There is little guidance for practitioners who may be the subject of death threats. These are clinically and ethically complex decision-making areas. Following a threat, the two immediate priorities for the doctor are the wellbeing of the patient and their own safety and that of their family and colleagues. The first may require the doctor to ask their departmental head for re-allocation of care. The second may require a range of actions by the doctor varying from increased vigilance to a relocation of work or even residence depending on the severity of the threat, as based on advice from law enforcement agencies.
On the basis of the limited literature to date,6,13 we recommend that healthcare organisations develop explicit policies of zero tolerance for threats. If threats are made, we suggest that doctors have personal and ethical duties to inform both their line managers and the police, and to transfer care of the patient in order to ensure that the patient receives the care they need. On one hand, informing the police could damage the doctor-patient relationship or deter a patient from help-seeking behaviour. On the other hand, a failure to inform might both put the patient, doctor and future practitioners at risk and deny the patient a thorough evaluation of specialist treatment needs. The decision to request transfer of care may carry value for both the patient and the doctor. The former may benefit from a fresh start with a doctor and an opportunity to develop trust. The latter may be in a position to afford personal space to reflect, allow time for personal healing and eliminate a conflict of interest.
This remains an area which is under researched and existing research is dated. An up to date large-scale survey of medical practitioners to ascertain the frequency and severity of threats, their impact on practitioners and patients, and predictors of outcome is required. Such information would help inform evidence-based guidelines. To ignore this issue would be to the detriment of doctors and patients alike.
Gautam Gulati, Consultant Forensic Psychiatrist in Ireland, and Graduate Entry Medical School, University of Limerick, Ireland
Colum P Dunne, Foundation Professor and Director of Research, Graduate Entry Medical School, University of Limerick, Ireland
David J Meagher, Foundation Professor of Psychiatry, Graduate Entry Medical School, University of Limerick, Ireland
Brendan D Kelly, Professor of Psychiatry, Trinity College, Dublin, Ireland
Competing interests: All authors read and understood BMJ policy on declaration of interests and have the following interests to declare: GG is Chair of the Faculty of Forensic Psychiatry of the College of Psychiatrists of Ireland. The views expressed are his own. CPD, DJM and BDK have no conflicts of interest to declare.
- American Medical Association Young Physicians Section . Violence in the Medical Workplace: Prevention Strategies. Chicago, Ill: AMA 1995.
- Owen J. Death Threats towards Psychiatrists. Psychiatric Bulletin 1992;16: 142-144.
- Wulfhorst E. Death threats, intimidation double at U.S. abortion clinics, group says. Reuters (online), 7th May 2018. Available at: https://www.reuters.com/article/us-usa-abortion-violence/death-threats-intimidation-double-at-u-s-abortion-clinics-group-says-idUSKBN1I82K1 (accessed 10th July 2019)
- Macdonald JM. Homicidal threats. Am J Psychiatry 1967; 124(4):475-82.
- Rothstein DA. Homicidal Threats. Arch Gen Psychiatry 1969;21(2):254–256. doi:10.1001/archpsyc.1969.01740200126025
- Brown GP, William R, Dubin WR, Lion JR, and Garry LJ. Threats Against Clinicians: A Preliminary Descriptive Classification. Bull Am Acad Psychiatry Law 1996; 24(3):367-76.
- MacDonald JM. The threat to kill. Am J Psychiatry 1963; 125: 1706-1711.
- Warren LJ, Mullen PE, Thomas SD, Ogloff JR, Burgess PM. Threats to kill: a follow-up study. Psychol Med 2008;38(4):599-605.
- Morrison JL, Lantos JD and Levinson, W. Aggression and violence directed toward physicians. Journal of General Internal Medicine 1998; 13(8): 556–561. doi:10.1046/j.1525-1497.1998.00167.x
- Harris A. Violence in general Practice. BMJ 1989; 298(6666):63-4.
- Gabe J and Elston M. ‘We Don’t Have to Take This’: Zero Tolerance of Violence against Health Care Workers in a Time of Insecurity. Social Policy & Administration 2008; 42: 691-709.
- Ventola CL (2014). Social media and health care professionals: benefits, risks, and best practices. Pharmacy and Therapeutics 2014; 39(7): 491–520.
- Frelier BS, Holwerda TJ. How to act in case of a homicidal patient; a literature review and a practice guideline. Tijdschr Psychiatr 2018;60(4):241-249.