Lecture XI: Ethics in the Care of Adolescents

Question 1

Describe the clinical conflicts in which the protection of confidentiality for pediatric patients may be in the best interest of the patient.

Answer 1

• Confidentiality is essential for patient care. May not come to doctor at all – adolescents less likely to seek medical care if they believe doctor will notify parents. Complete history essential for diagnosis/rx.
• Confidentiality imp for societal welfare. Treatment/containment of contagious disease. Health imp for economy. Eagleton (1972) effect on psych visits.
• When treating older adolescents, pediatricians often preserve confidentiality on topics relating to sex and substance use (more questionable with middle schoolers)
• Value the child’s trust and don’t want to lose it
o Want to be a source the child trust if things get worse
• The balance changes in part based on what the level of the health risks are, how mature that young person is, how much parental oversight they’re receiving
• Role as physician is different than role as a parent- lose trust of child, you’ve lost a lot and they wont’ tell you what’s going on in the future, and that’s not in the best interest of the child or the parent
• When adolescents perceive that health care services are not confidential, they report that they are less likely to seek care, particularly for reproductive health issues or substance abuse

Question 2

Describe clinical conflicts in which the violation of confidentiality (paternalism) may be in the best interest of the patient.

Answer 2

Exceptions to confidentiality
Consent:
• Competency required
o Ability to understand consequences of one’s action
o Adolescents typically capable of reasoning like adults around age 14 years
• 3rd party payment (insurance company, Medicaid)
• Share information with treatment team (N=50)
• Education of students/ residents
Statutes/ court decisions
o Child abuse reporting
o Contagious disease reporting
o Need to balance interests of society vs individual
o Empiric question of what is most effective way to protect societal interests

Other possible exceptions:
• harm to others
o violence (Tarasoff)
o STDs
o Future possible children (teen pregnancy)
• Harm to self (suicide)
o Evidence that 95% want to be stopped; later most say “thank you”
• Letters of recommendation (?): disabling medical/ mental illnesses in students/ residents
• Parental interest in child rearing

Question 3

Define “emancipated minor”

Answer 3

• Emancipated minor: An emancipated minor is a minor who is allowed to conduct a business or any other occupation on their own behalf or for their own account outside the influence of a parent or guardian.4
• Most states is either set at 18 years old or requires the person be either both 18 and out of high school or at least 20 years old), at which point they become adults. However, in special circumstances, a minor can be freed from control by their guardian before turning 18.
o Examples; marriage, obtaining degree, military service, attaining economic self-sufficiency
• Mature minor: A mature minor is a person sixteen years or over and under the age of eighteen (who has demonstrated the ability and capacity to manage his (or her) own affairs and to live wholly or partially independent of his (or her) parents or guardians.

Question 4

Explain parents’ interests in raising their children congruent with their own values

Answer 4

Parental interest in child rearing
o Family as critical unit of society
o Family as central source of values education
o Doctor colludes w/ adolescent in deceiving parents
o Enables/encourages risky behavior w/out parental oversight