What would you advise in this situation? Why?

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It's not about anyone in particular.

Say that a man has a problem. For years he's been hallucinating. Voices, people, creatures. He's not sure whether he believes in these things, because he knows that things like that don't happen, yet..they do for him.
The man starts getting urges. Some of them resemble OCD, others could be the urge to kill someone, make clothing out of their skin, and eat their meat.
The man acknowledges that these things are not normal, and he feels that he has the self control to never become a threat to anyone. Whenever he's alone, though, they return to his thoughts. He always arrives at the same outcome, that he would never act on his less acceptable urges, but sometimes it's a close thing. Sometimes he catches himself rationalizing the urges and the rationalizations make sense.

He can keep it to himself. He runs no risk of discovery..if he keeps it under control. He then risks the safety of another person.
He can confide in strangers on the internet. He runs a greater risk of discovery, but he can get things off his chest assuming that the environment remains friendly.
He can tell his friends or family. It will spread to everyone in the family, or his friend's friends. He runs the risk of losing the support of these people, and they will never look at him the same way. He might receive real help.

Which would you choose, or give another option, and why?

My advice would be medication and a psychiatrist. I takes a very strong person to recognise these thoughts as abnormal and possibly dangerous and therefore makes an effort to stop them.

Thinking that is not illegal, but just because someone chooses not to act does not mean they are not unwell.

Yeah, I agree-- seeing a professional is the best option. The thing with telling your peers or family is that they might be overwhelmed just as you are. I'd only really tell an individual you know for sure you can trust, family is loving but the thing you can normally trust family (a good one) to do is to do what 'they' think is in your best interests.

Also by "sure" you can trust I don't mean the first nice person that comes to mind, I mean someones who's as good as anonymity as a priest in a confessional booth.

If the rationalizations of the awful actions make sense enough to override his awareness that those awful actions aren't acceptable outcomes, he needs help and support.

In general, risking another person's life on a "close thing" is not reasonable. But, which kind of help and support depend heavily on factors not mentioned in the question. It will not be sensible for me to deliver a verdict on which of two of the options is best.

The "confide in strangers on the internet" option does not seem reasonable. If the man-with-the-problem finds this option provides significant relief, the urges are already urgent enough to place another person at risk. So the "tell random strangers on the internet" option is an unsound steady-state option, except perhaps in weird exceptional cases.

As others have mentioned, seeking a professional may be the wisest choice to start with.