Federal and state statutes legislating a minor’s right to medical confidentiality are often vague, and many times the decision whether or not to disclose medical information is left to the doctor’s discretion. According to Dr. Joe Sanders Jr., former executive director of the American Academy of Pediatrics (AAP), most pediatricians make a verbal “contract” with the parents and the teenager regarding confidentiality. It is mutually understood that any information the young patient shares with the physician remains in strict confidence unless in the doctor’s judgment the teen poses a danger to himself or to others or has been abused.
“For instance,” says Dr. Sanders, “if a teenager tells me, ‘I’m really depressed and I’ve been thinking of killing myself,’ I cannot hold that information in confidence, because I’ve got to get this kid the proper help. But if an adolescent tells me that he is sexually involved with his girlfriend, and he doesn’t want his parents to find out, I won’t share that information. I will work with him to minimize the risk of contracting a sexually transmitted disease or having an unintended pregnancy.”
Teenagers’ concerns about confidentiality can be a major barrier to obtaining health care. In a Louis Harris/Commonwealth Fund poll of more than six thousand five hundred teens, nearly one in three high-school girls and nearly one in four high-school boys admitted to at least one occasion when they needed medical care but did not see a doctor. The number-one reason given: They did not want their parents to know. So it is important to remember that “the pediatrician serves both generations,” in the words of Dr. Morris Wessel, now retired after nearly half a century of practicing pediatrics.
What Is Informed Consent?
Since the 1970s, the U.S. Supreme Court and many state legislatures have expanded the rights of minors to make health-care decisions for themselves. These laws were enacted not to undermine parents’ authority, but in recognition of the reality that harmony and open communication do not reign in every family. In cases where notifying a parent would pose an obstacle to an adolescent’s receiving needed medical care, the boy’s or girl’s right to privacy supersedes the parent’s right to know.
Examples include abortion, obtaining birth control and screening for the HIV virus, as well as treatment for AIDS and other sexually transmitted diseases; mental health problems; substance abuse; and rape, incest or sexual abuse. The majority of teenagers who test positive for HIV or who desire an abortion do tell their moms and dads. It’s not surprising; they’re usually scared and upset, and desperately want their parents’ love and support. When kids choose to keep their condition a secret, it’s frequently because they fear their parents will react violently, or throw them out of the house.
Minors do not have unrestricted access to health care, however. A concept known as the Mature Minor Doctrine provides physicians with general guidelines for determining when to provide medical treatment based on an adolescent’s consent. (Some states have adopted the doctrine as law; in other states, it is not on the books, but the courts acknowledge that the principle exists.)
One requirement is that the young patient must be sufficiently mature to fully understand the nature of the proposed treatment, including its benefits and risks. The rather subjective decision as to whether or not consent is informed rests with the physician. According to Dr. Robert Brown of Children’s Hospital in Columbus, Ohio, few pediatricians would allow a thirteen-year-old to authorize her own medical care, “because it isn’t until later that youngsters have the cognitive ability to think in an adultlike manner.”
Another major consideration is whether or not trying to secure a mother’s or father’s consent would delay the treatment, and if so, would deferring therapy endanger the young person’s health? In a medical emergency, the treating physician usually may institute treatment without the consent of the family or the patient.