JEFFREY NICHOLS is president of the New York Medical Directors Association. He also is cofounder of the New York Long-Term Care Ethics Network and is a long-time member of AMDA's Ethics Committee. The views expressed in this column are those of the writer. A resident whom we will call Mrs. G was referred to the Ethics Committee because her social worker believed her privilege to go out on pass should be revoked. Mrs. G transferred to the home from another facility to be “closer to her family.” She was a 74-year-old woman with a previous medical history of hypertension; insulin-dependent diabetes mellitus; elevated cholesterol levels; a cerebellar infarct, which had precipitated the original nursing home admission; two myocardial infarctions; and mild dementia. At the time of admission, Mrs. G was supposed to be taking 14 medications. She had been poorly compliant at home, however, and had multiple admissions for decompensated medical conditions. After a brief course of physical therapy, Mrs. G was independent in ambulation and transfers with a cane, independent in all other activities of daily living, and oriented to person and place with some disorientation to time. From the time of admission, all staff had found Mrs. G to be an engaging, albeit foul-mouthed, elderly lady with a flamboyant style of dress that included numerous bangle bracelets and 10–15 strands of beads on a typical day. After admission, however, her social history became clearer. Mrs. G had an extensive rap sheet with multiple arrests for larceny and prostitution (the last when she was well into her 60s). She had a long history of ethanol abuse combined with chain-smoking of tobacco or marijuana and occasional dabbling in narcotics. The family she wished to rejoin included her common-law husband, who was too sick to visit her because of terminal AIDS, and two daughters by two men other than her common-law husband. Both daughters appeared to have joined the family business; one was barred from visiting beyond the lobby after her crack pipe was found in Mrs. G's room. Initially, the staff either tolerated or enjoyed Mrs. G's lifestyle. But other residents frequently noticed that they were missing personal items that later appeared in Mrs. G's wardrobe or were found in her nightstand. One 90-year-old lady struck Mrs. G with a cane when she tried to take a sweater draped over the back of the woman's chair. Mrs. G was counseled about taking other residents' possessions and agreed to follow the home's rules. Mrs. G had requested a pass to go out for brief walks in the neighborhood. She could walk two to three blocks unassisted, and there was no doubt that she could find her way back to the facility. She stated that being stuck in the nursing home was “like being in prison,” a metaphor that seemed particularly apt considering her history. Meanwhile, the social worker noticed that Mrs. G's costume jewelry collection was growing rapidly, despite her complete lack of funds. Most of the objects still had tags from local stores. She concluded that Mrs. G was shoplifting. Traditional medical ethics cases typically revolve around invasive procedures or care management at the end of life. In this case, the issue—if we choose a medical focus—is the physician's order for a level of activity. But the deeper issue is the balance between the clearly expressed wishes of the patient and a perceived need to protect other nursing home residents and the outside community from a predator. There is no argument that going out was in any way bad for the patient. From her viewpoint, there were no risks (even if caught, she would not have been arrested; she could not have been safely incarcerated). The risks were entirely to the reputation of the nursing home and the finances of local shopkeepers. Does the physician, or any health care facility, owe a duty to the larger world that might outweigh its duty to the individual patient? Many would argue that the nature of the doctor-patient relationship demands that physicians hold all other interests secondary to individuals under their care. The large television audience that follows “House” enjoys the portrayal of a cantankerous physician who clearly embraces this view. In various episodes, he has lied about patients' conditions to get them into experimental protocols or onto transplant lists, helped a Munchausen's patient fake an illness to get into the hospital for care of a genuine medical problem, and happily ordered millions of dollars of minimally indicated tests at the expense of society or his hospital. Yet, despite his outrageous verbal and sexual antics, Dr. House is put forth as heroic because of his diagnostic brilliance and his determination on behalf of the patients in whom he deigns to take an interest. I would argue that physicians do have obligations that transcend the individual patient. For example, mandatory reporting of certain contagious diseases requires physicians to violate the privacy of an individual patient on behalf of the public good. Reporting sexually transmitted diseases may, in fact, cause some harm to a particular patient when contacts are identified and informed, but obviously serves those who are at risk. Psychiatrists are required to violate patient confidentiality when they learn of potential physical risks to others. But they aren't required to reveal confidences of patients who might simply be planning to take some cash from Grandma's purse or steal a car. A legal, and perhaps an ethical, distinction is made between physical and material injuries. Similarly, in this case, if Mrs. G revealed to her physician that she was planning to go out to pilfer some attractive bauble, there would have been no obligation on the physician's part to warn the shopkeeper. The justification for maintaining patient secrets is that without the confidence that their privacy will be maintained, patients will not reveal to their physicians the information required to render appropriate care (if we don't know that elderly Mrs. M is sleeping with the pool boy, we might not think about gonorrhea when we consider her right upper-quadrant pain). However, in this case, there is no privileged medical or personal information at issue. What was being asked was not what a responsible physician should do in this situation but what a good neighbor would do. If you knew or suspected that your next-door neighbor was siphoning gas from the cars on your street, would you try to keep him inside—or would you warn others? Would you try to counsel him—or just get a lock for your gas tank? The Ethics Committee decided to recommend that Mrs. G's pass privileges be continued on the condition that she be accompanied by a staff member. Administration was less than delighted with this plan, because it seemed to set a precedent for one-to-one staffing, but accepted it on a trial basis. However, Mrs. G found that shopping with an observer and paying for what she took was much less attractive than her prior practices. She decided that her need for fresh air could be as easily satisfied by sitting on the back patio with a pack of cigarettes. The Medical Ethics column runs every other month. If you have questions related to this column or would like to submit cases for possible discussion, e-mail us at .