Medical ethics case file

Medical ethics case file

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 8

A 16-year-old adolescent girl presents to your office with the complaint of greenish vaginal discharge for the past 2 months and the recent onset of lower abdominal pain. She reports that her last period was about 2½ months ago. She is sexually active with two partners and has never used a condom or any other contraception with either. On physical examination, she is not febrile with normal blood pressure and pulse. She has greenish discharge from the cervix with friability and cervicitis. There is no cervical motion tenderness. Her urine pregnancy test is positive. Acervical sample is positive for Chlamydia and negative for Neisseria gonorrhoeae. Her rapid plasma reagin (RPR) is nonreactive and an HIV test is negative. The patient is treated with appropriate antibiotics and counseled concerning safer sex practices. You also inform the patient regarding her risk for HIV conversion, even though today's test was negative. The patient asks if you are going to tell her mother that she is pregnant and has this infection. You inform the patient that because of patient confidentiality and ethical considerations you will not disclose this information to her mother without her consent. She tells you that she does not want her mother and boyfriends to know that she is infected.

⯈ What should you do?

⯈ What should you tell the patient?

⯈ What are the ethical considerations?

⯈ What are the guidelines for reporting communicable diseases?

ANSWER TO CASE 8:

Medical Ethics

Summary: The patient is a teen who is pregnant and has a sexually transmitted infection (STI). She engages in high-risk sexual behaviors.

• What you should do and tell the patient: You must inform the patient that you have to contact the state health department. The department will contact her and her partners without disclosing her identity. You might also advise the patient to cooperate fully with the health department to avoid phone calls or letters received at home. It is also important to stress to the patient the importance of protecting her partners by telling them her diagnosis. She may avoid further exposure if her partner(s) are adequately treated.
• Ethical considerations: Teenage pregnancy, confidentiality, sexually transmitted infection reporting, and emancipation.
• Guidelines for reporting communicable diseases: The guidelines for reporting communicable disease vary slightly from state to state. However, there is usually a formal mechanism for reporting to the state department of health. The physician may do it himself/herself or may elect to use an agent, such as a nurse or other medical facility staff member. It is a federal mandate to report communicable diseases; failure to do so may result in adverse legal, civil, and even criminal actions. For example, in the state of Texas, failure to report communicable diseases (HIV / AIDS, gonorrhea, chlamydia, chancroid, and syphilis) is considered a class B misdemeanor.

ANALYSIS

Objectives

1. Discuss confidentiality and its ethical and legal considerations when treating adolescent or pregnant adolescent patients.
2. Understand the legal obligations for reporting communicable diseases and informing partners.

Considerations

There are several considerations involved in this case. The first issue is pregnancy. In some states, the patient would be considered emancipated. Consequently, legally she can make decisions regarding her pregnancy -related health care (excluding abortion in most states) without notice to or the express consent of her parents. In addition, she has a sexually transmitted infection, which is a reportable condition; thus the physician or the physician's agent must report this to the state health department for surveillance and infection control. She is also very concerned about informing her partners about the infection. There are also issues of confidentiality.

Approach To:

Medical Ethics

DEFINITIONS

EMANCIPATION: Emancipation is a legal process in which a person who is younger than 18 years petitions the court to have herself/himself declared a legal adult. Laws for emancipation vary by state. Emancipation ends the parents' legal duty to support the minor, and also ends the parents' right to make decisions about the minor's residence, education, health care, and to control the minor's conduct. However, this does not include the ability to consume alcohol, use tobacco, or exercise voting rights.

MATURE MINOR DOC TRINE/RULE (JUDICIAL BYPASS): The mature minor exception to the need for parental consent for medical care is based on the West Virginia Supreme Court case Belcher v CAMC. Statute and court decisions in many states may vary. A minor may consent to receive medical care without the consent of the parents or guardian if deemed "mature'' by the judicial system.

CLINICAL APPROACH

According to the Society for Adolescent Medicine, "the overall goal in clinical practice is to deliver appropriate, high-quality health care to adolescent patients, while encouraging communication between parents or other trusted adults without betraying the adolescent's trust in the health-care professional:' It is very important to gain the confidence of adolescent patients because if the patient does not believe that the health-care provider will keep the patient's health information confidential, the patient is less likely to seek health care when needed. Confidential health care should be provided for all adolescent patients; however, the physician must consider some very important issues: Is the teen self-supporting? Is the minor mature enough to make his or her own medical care decisions? Would disclosure without consent harm the patient?

Ethics

Ethical considerations when treating adolescent patients can be complex and one should use the moral principles of ethics, which include autonomy, beneficence, nonmaleficence, and justice to guide clinical decisions to maintain confidentiality. Respect for autonomy should involve respect for the patient's wishes, choices, and beliefs when deciding what is best for the patient. It is important to understand the dynamics of the parent-child relationship and why the teen does not want to disclose important medical information to parents. This type of dialogue may reveal very important things about the child's current situation and help to guide your decision making. Knowing the intricacies of the family dynamic may also help the clinician and the patient develop solutions to aid in disclosure of very important health-related issues.

Nonmaleficence implies that the physician will do nothing to harm the patient, which includes emotional and psychological harm. Failure to maintain confidentiality may result in some emotional distress for the patient. Moreover, the physician should not apply the same moral standards to every patient. Some teens are more mature than others and the physician should use his or her judgment with each adolescent patient.

In addition, the treating physician should apply the principle of beneficence, which requires action to further a patient's welfare. In other words, do the right thing for the patient. Maintaining confidentiality may aid in full disclosure of symptoms, life situations, and so on. Full disclosure of pertinent medical information can help the physician provide the most comprehensive care to the patient.

Justice implies the fair and unbiased treatment of the patient regardless of age, sex, or ethnicity. Consequently, adolescent patients should be given the same level of care as adults, without having the fear of disclosure, when they are mentally capable of receiving care.

In most cases, every attempt should be provided to ensure confidentiality. However, there are instances when it would be in the best interest of the patient to disclose medical information. Examples of these situations could include patients with homicidal or suicidal ideation or serious chemical dependence, and in suspected cases of abuse. Disclosure of medical information should only be considered when the life of the adolescent must be protected. It is also important to point out that, in most cases, adolescents are not responsible for payment of medical services. The parent or the guardian usually has to assume the responsibility for payment. Thus, the maintenance of confidentiality in these cases is an issue. Because there are no clear-cut guidelines in this situation, it is important to encourage open dialogue between the patient and the patient's parent. However, in instances when this is not possible the physician must use his or her own clinical judgment while considering ethical issues and must act in the best interest of the patient.

Legal Considerations

There are laws in place to protect the confidentiality of health-care information. In general, the law requires the consent of the parent when health care is provided to minors; there are, however, exceptions, such as emergencies, care for the "mature minor," and when the minor is legally entitled to consent to their own medical treatment.

Laws that allow minors to consent to medical treatment vary from state to state. In some states minors are allowed to consent to medical therapy based on status, such as emancipation, marriage, pregnancy, living apart from parents, and when given the status of "mature minor:' The mature minor rule was created in 1967 and is based on the West Virginia Supreme Court case Belcher v CAMC, which allowed health-care providers to treat a youth as an adult based on an assessment and documentation of the adolescent's maturity level. According to this decision, a court must determine that a minor is deemed mature, which determination is based on various factors, including age, ability, experience, education and/or training, degree of maturity and/ or judgment exhibited conduct and demeanor, and capacity to understand the risk and benefits of medical treatment. The process to become a mature minor is known as judicial bypass and may vary from state to state. This exception to parental consent must be received from a court.

In addition, adolescents may consent to medical care if they are considered emancipated. Emancipation implies that a minor must be of a certain age (which varies by state), must live apart from his or her parents, and must be self-sufficient. Minors are also considered emancipated if they are self-supporting, not living at home, married, pregnant or a parent, in the military, or declared emancipated by the judicial system.

In some states, consent to health care may be based on the type of care the adolescent is seeking. Examples of the types of health-care services that may be obtained without parental consent may include maternity services, contraceptive management, treatment and diagnosis of sexually transmitted infections (including HIV) or other reportable diseases, treatment of drug or alcohol problems, and care related to sexual assault or mental health services. These provisions are very important because they allow the necessary assessment and treatment of important health-related issues. Moreover, research shows that adolescents are more likely to seek medical care if confidentiality is protected.

Reportable Diseases

Reporting STIs, HIV, and other reportable illnesses can be stressful for the patient. This may be particularly stressful for the adolescent. The information may be reported by the physician or by the physician's designated appointee. All those involved in the oversight of blood products, including clinical laboratories or blood banks, are also required to report STIs and other reportable conditions to the state's health department. It is state and federal law that these illnesses be reported in a timely fashion to the state health department.

In addition, it is mandatory that the information be disclosed to partners. Partner reporting is a way to control the spread of disease and to ensure prompt and proper diagnosis and treatment of all those who may be affected. Partner notification can occur in either of two ways: by patient referral or by the department of health staff. The patient can contact his/her partner(s) for referral, diagnosis, and treatment. Alternatively, the partner(s) may be notified and counseled by department of health staff, if the patient is unwilling to inform them. In the setting where a patient is unwilling to inform his/her partner(s) of a reportable illness that places the partner(s) at risk, the health-care provider has a legal and ethical obligation to inform the partner(s) (if known by the provider) that they are at risk.

Teenage Pregnancy and Confidentiality

Issues regarding teenage pregnancy and consent to disclose information regarding pregnancy are quite controversial. Laws for reporting vary by state and the specifics may become quite daunting. For the purposes of this case, focus is limited to generalities. One must understand the laws pertaining to this issue in the state in which he or she practices. In the state of Texas, as may be the case in other states, a clinician is not required to inform the parents of issues related to the pregnancy of a minor without the child's consent, but it is not mandatory for the adolescent to give consent for a physician to disclose information related to pregnancy to parents.

However, studies demonstrate that failure to maintain confidentiality in "sensitive" health-related issues may inhibit appropriate health-care delivery to the adolescent.

In Texas, the law does not allow state funds to be used for contraception without the consent of the parent. Moreover, in most states, an adolescent younger than 18 years cannot give consent to abortion services without the consent and/or notification of one or both parents. This issue has been the subject of political debate for many years. Proponents of mandatory consent laws believe that it is in the best interest of the minor for her parent(s) or guardian to be informed of her pregnancy and decision to obtain abortion services, stating that by doing so, communication among adult and child may be improved.

Opponents of these laws, however, see them as a threat to the well-being of young women by forcing them to seek abortion services from unlicensed facilities, crossing state lines to obtain abortions, and increasing medical risk. The risk to young women may be increased by enforcing mandatory wait periods. Young women are at greater risk of having abortions later in the pregnancy.

Currently, only twelve states and the District of Columbia do not require consent from and/or notification to parents to obtain abortion services. In a state in which consent is required, there are some legal alternatives for young women. For example, if an adolescent is considered emancipated, then consent from parents or guardians is not required. Waivers of consent (judicial bypass) may also be obtained through the judicial system.

Emergency contraception (EC) when taken after sexual intercourse can prevent pregnancy by disrupting or delaying ovulation or fertilization. Some states allow EC to be accessed without a prescription in individuals 17 years and older. Certain states require that EC be given or offered to sexually assaulted victims in emergency departments. There are significant discrepancies from state to state and future changes are expected.

Conclusion

Pregnancy-related care, abortion services, and reportable illnesses are complex issues and a clinician should seek legal advice when appropriate. However, in general, it is preferable to protect the confidentiality of the minor unless it is unreasonable or unsafe to do so. It is also important to educate teens and parents of the importance of open communication and issues related to confidentiality in medical care.

COMPREHENSION QUESTIONS

8.1 A 14-year-old adolescent girl is here to see you for complaints of greenish vaginal discharge. She is sexually active with one partner and does not use condoms. You do a culture and find that she has Trichomonas vaginitis. She asks you not to tell her mother about this diagnosis or that she is sexually active. Which of the following statements is most accurate regarding disclosure or nondisclosure of this information to her parents?

A. You can keep this information confidential. However, it is advisable to talk with the teen about her sexual history and discuss communication issues between her and her parents.

B. Since she is a minor, you must disclose this information to her parents.

C. You can only keep this confidential for today for enhancing therapy, but then disclosure to the parents must be demonstrated and documented.

D. You may keep this confidential from the parents but you must call the partner to notify him of the infection.

8.2 In which of the following situations may a physician keep information confidential from parents or other authorities?

A. The physician finds injuries consistent with physical abuse while examining a 13 years old, but the patient fears further injury if the abuse is reported.

B. A depressed teenager reports a strong desire to kill herself and that she has secretly obtained a gun that she keeps in her bedroom.

C. An undocumented immigrant patient has active tuberculosis and fears deportation if the illness is reported.

D. A 19-year-old female college student, who is still on her parents' insurance plan, reports a consensual sexual relationship with a 35-year-old man and requests contraception, but does not want her parents to know.

8.3 Which of the following is most accurate regarding the term "emancipation'' as it applies to a minor?

A. Able to vote

B. Able to purchase and consume alcohol

C. Able to make their own medical decisions without parental consent

D. Legally financially independent

8.4 Which of the following statements regarding a minor's ability to consent for an abortion is most accurate?

A. Because of medical confidentiality, a minor is able to consent to any medical therapy she chooses without the consent of her parents or guardian.

B. Although consent requirements for abortion services vary depending on the state, most states either have some form of required consent for abortion services to minors or a mandatory wait period.

C. There are no states in which a minor can obtain an abortion without the consent of a parent or guardian.

D. A minor cannot consent to any medical therapy without her parents' approval unless she has received a court order.

ANSWERS

8.1 A. The law does not require the disclosure of sensitive medical information to parents. However, in some states it is not forbidden to disclose that information. A clinician must use his or her best judgment when deciding whether to disclose medical information. More importantly, the physician should recognize the importance of confidentiality when treating patients and encourage open communication between adolescents and parents when it is reasonable to do so. Partner notification can occur by patient referral or by health department staff.

8.2 D. All states have laws mandating the reporting of certain conditions, even if the patient objects. The specific conditions may vary from state to state, so the physician must be aware of the rules where he/she practices. Child abuse must be reported to appropriate authorities if suspected in all states. Similarly, certain infections, such as active tuberculosis, must be reported to public health officials. Active suicidal ideation, especially if there is a plan and access to agents necessary to implement the plan, may lead the physician to intervene to prevent the action. Of the scenarios listed, only D does not obligate the physician to act.

8.3 C. Emancipation implies that the patient is able to make decisions regarding health-related issues but does not give the patient the right to vote, consume alcohol, or use tobacco products if the patient is not of legal age.

8.4 B. The laws regarding the consent for abortion services vary from state to state. Only 12 states currently allow a minor to have an abortion without the consent of or notification to parents.

CLINICAL PEARLS

⯈ Adolescent health care is a complex issue. However, the clinician should attempt to administer confidential health care to minors seeking care for sensitive medical issues when it is safe and appropriate to do so.

⯈ It is very important for clinicians to know the laws regarding consent and confidentiality when treating adolescent patients of the states in which they practice.

REFERENCES

Boonstra H, Nash E. Minors and the rights to consent to health care. The Guttmacher Report on Public Policy, Volume 3, Number 4, August 2000. Available at: http://www.guttmacher.org/pubs/ tgr/03/4/gr030404.html. Accessed March l, 2015. 

Center for Reproductive Rights. Mandatory parental consent and notification laws. Item F039. March 2001. Available at: http:/ /www.reproductiverights.org. Accessed March 1, 2015. 

Cundiff D. Clinical case. Available at: http://virtualmentor.ama-assn.org/2005/10/pdf/ccasl-0510. pdf. Accessed March 1, 2015. 

Ford C, English A, Sigman G. Society for Adolescent Medicine position statement. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Med. 2004:35:160-167. 

Litt I. Adolescent patient confidentiality: whom are we kidding [editorial Jr] Adolesc Health. 2001;29:79. 

Maradiegue A. Minor's right's versus parental rights: review of legal issues in adolescent health care. J Midwifery Womens Health. 2003:48(3):170-177. 

Parental consent and notification laws. Planned Parenthood. Available at: http://www.plannedparenthood. org/health-topics/ abortion/ parental-consent-notification-laws-25268.htm. Accessed March 1, 2015. 

The Guttmacher Institute. State polices in brief emergency contraception. Available at: http:/ /www. guttmacher.org/ statecenter I spibs/ spib_EC.pdf. Accessed March 1, 2015.

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