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This article discusses managed care, recent case law developments, and the legal basis of confidentiality in the patient-therapist relationship. It discusses how managed care intrudes into the confidential treatment relationship with prospective and retrospective utilization reviews. Some of the areas adversely impacted include public policy, the patient-therapist relationship, and informed consent. In order to be a program in the interest of patients and not simply cost containment, managed care must accommodate patients' reasonable expectations of confidentiality. Suggestions are delineated for the protection of confidentiality by managed care, including expanding the duty of confidentiality to managed care, obligating managed care to secure patients' informational privacy, obtaining informed consent to disclose as little information as necessary, and involving the patient in the cost containment and quality assurance process.

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A CASE STUDYnineteen-year-old girl, with a fifteen-year history of intermit-A tent neurological problems, was a patient in a neurology ward of a university teaching hospital. When she entered the hospital she had complained of muscular weakness and difficulty in breathing. Her diagnosis was uncertain but there was evidence that her brainstem had deteriorated from unknown causes. Several physicians and their consultants had been unable to diagnose, arrest or reverse her decline. As her illness progressed, she gradually lapsed into a coma and did not regain consciousness. A ventilator was necessary to enable her to breathe. After several weeks her physicians recommended to her family that a no code order be written so resuscitation would not be attempted if she suffered a cardiac arrest.During the course of her illness, her family kept a twenty-four hour vigil by her bedside. Her mother, stepfather and three younger siblings rotated shifts to be with her. The family, all devout Catholics, had suffered through her previous neurological episodes. They hoped that, as before, she would eventually recover. But it became increasingly clear that this illness was extremely serious and intractable to treatment. A few weeks after the no code order had been written, the patient was still comatose and her condition continued slowly to worsen. Attempts to wean her from the ventilator were unsuccessful. At this point the physicians believed that no further therapeutic options were available. It was suggested to the parents that they consider removing the ventilator because it provided no therapeutic benefit other than to prolong the patient's existence in an irreversible coma. The parents requested a consultation with someone who could advise them of their legal and ethical rights and responsibilities.The legal issues were sensitive but not difficult to grasp. The patient, though legally an adult, was emotionally and developmentally immature, in large part because o f disabilities arising out of previous neurological problems. Because she was now comatose, she could not speak for herself. When she had entered the hospital, as she had numerous times before, she had not Q 1985 by The