Confidentiality and Adolescents Show
Case DiscussionA 14-year-old accompanied by her mother presents with complaints of nausea and vomiting for two weeks. After her mother leaves the room, she admits to being sexually active and tells you that she has had unprotected intercourse recently with her boyfriend and missed a period. Her parents do not know she is sexually active, and she does not want her mother to know that a pregnancy test is being done or the result of that test. Pregnancy test comes back positive. This patient, a 14-year-old, has requested that you not convey to her mother that a pregnancy test has been sent. In other words, she has requested that you respect her confidentiality. We talk about confidentiality. What is the rule of confidentiality, and how does it differ from respecting someone's privacy?Distinction between violations of confidentiality and privacy:
Is there a general duty of confidentiality, and what is the basis for this general ethical rule?There should always be a strong presumptionto respect confidentiality and avoid breaking confidences when at all possible. The duty of confidentiality is based on four major arguments:
Is there an obligation to maintain confidentiality when the patient is an adolescent?Adolescents' concerns about confidentiality can be a barrier to accessing health services (Booth, Ford, Reddy, Cheng, Klein). When they know that confidentiality will be respected, they are more likely to seek healthcare, return for healthcare and disclose sensitive information about risky behaviors (Ford). One study (Reddy) of girls ages 12 to 17 in the United States found that nearly 60% reported that if their parents were notified, they would stop using all or some sexual health services or delay testing or treatment for sexually transmitted infections. Other studies have found that about a third of adolescents would not seek health care for sensitive health concerns if their parents could find out (Cheng, Klein). The majority of adolescents wish to obtain healthcare for some or all of their health concerns without parental knowledge (Thrall). One in 10 adolescents reported not visiting their health care provider in the previous year despite wanting to do so because of the fear that their parents would find out (Thrall). This study also found that the provision of confidential healthcare was a significant predictor of having discussed substance use with providers in the preceding two years. One British survey of 188 adolescents ages 16 to 17 found that 85% of them ranked confidentiality as the first- or second-most-important issue in seeking health services (followed by telephone advice, written information, special clinics, friendliness and magazines in waiting room) (McPherson). Another survey found that 58% of adolescents had health concerns they wished to keep private from their parents. Due to concerns about privacy, only 57% were willing to see their physician about sensitive subjects (Cheng). Doesn't the law require we tell parents these things?Laws regarding confidentiality vary from state to state. In Washington state, confidentiality is tied to informed consent, such that any individual who can provide informed consent (and most adolescents can provide consent for diagnosis and treatment of STDs, pregnancy, contraception and psychiatric care) is also owed the duty of confidentiality. How will you strategize what happens next, e.g., sending a test while the girl waits, but not telling the mom what has been done?What is perhaps most important is to make a plan with the girl. One option is to suggest that a visit to a public health clinic or Planned Parenthood might be a safer way to protect her confidentiality. If she wants you to perform the pregnancy test, then she needs to be aware that her mother may have questions about what is happening and why tests are being done. It will also be necessary to plan for how the test result will be shared once the mother is back in the room. What if her mother asks what tests you are doing?While you have promised confidentiality to the daughter, this does not require that you lie or mislead the girl's mother. The daughter needs to understand this. If asked a question by the mother about what tests are being done, you may need to say that you cannot divulge that to her. In that case, an uncomfortable situation may arise with the mother confronting the daughter. The physician's duty in this case is to make the daughter aware of this risk of doing the test now with her mother present. Is it ever appropriate to violate the duty of confidentiality? If so, under what conditions?The clearest situations in which confidentiality can be justifiably overridden are those in which the patient places another person or the community at significant risk of serious harm.
What are some examples where breaking the rule of confidentiality might be justified?
What about harm to self? Is your feeling that the adolescent might harm herself or that she might later regret her decision sufficient reason to break the rule of confidentiality?These are referred to as paternalistic violations of confidentiality: "It is done for the patient's own good." Paternalistic violations of confidentiality are rarely justified in adults, especially regarding those patients who demonstrate the capacity to make the decision in question (understanding of issues, thoughtfulness, ability to make a decision, awareness of and willingness to accept consequences). Notice that a breach of confidentiality is not justified simply because you think it would be better for the patient if others knew about a certain condition or problem. Respect for persons requires that a person with capacity be permitted to decide whether or not it would be beneficial to herthat others know the information in question. Adolescents should be encouraged to consult with parents about decisions. Confidentiality should only be violated if what the adolescent has revealed suggests there is a strong likelihood of serious harm to them; that the harm will most likely be prevented by breaking confidence; that all alternatives have been exhausted; that they have been given the opportunity to make the revelation themselves; and that they have been notified of your intention to break confidentiality. This is more easily justified if there is some evidence of limited autonomy on the part of the adolescent. If you decide you must break confidentiality, what are your obligations to the adolescent patient?
If you decide to maintain the confidentiality of your adolescent patient, what are some of the ways confidentiality may not be maintained?Mark Siegler has asked whether confidentiality is a "decrepit concept." He had a patient express his concern over the number of people who appeared to have access to his inpatient chart. Siegler counted 75 to 100 people with legitimate reasons to be looking at the chart. When he informed the patient of this, his reply was: "Perhaps you should tell me just what you people mean by 'confidentiality!'" Likewise, when a physician at an East Coast institution had an HIV test done at his home institution, within hours he had acquaintances approaching him to offer their sympathy. In this case, the girl was notified that her pregnancy test was positive and persisted in her request that her mother not be told. Does she need to know about other ways her parents may find out about the test result even though you have promised not to divulge that information without her permission?
Conclusion with SuggestionsHave a standard discussion with all adolescents at the beginning of a visit (warning of limitations on your ability to maintain confidentiality): "What you tell me here is between you and me. I will not tell your parents or others about what we have discussed without your permission. "However, I want you to be aware that there are certain circumstances under which I will not be able to keep that promise. For example, if what you tell me suggests that you intend to harm yourself or place someone else at risk of serious harm, I will need to share that information. "You should also understand that your parents will get a bill for this visit and may ask you about it. That bill may have the names of tests that we do today…" If there is no mechanism in place to restrict access to the records of adolescent patients, they should be warned that parents may have access to their records (if they request them), and that you may not be able to prevent that possibility (even in states that respect minors' desire to have records not be revealed to parents, it may happen inadvertently). Make a plan with the adolescent regarding follow-up of lab results and billing to assure confidentiality. Do not leave messages on answering machines. Likewise, recognize that fax and email communications can easily be sent to the wrong person. Make a plan with the adolescent regarding how she wishes to be contacted by you for follow-up on lab results. Confidentiality and Adolescents1. Instructor's Guide 2. Student's Guide 3. Case Discussion This instructor's guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's. In addition to the copyright notice set forth in the link below, permission to display, cache and print unlimited copies of the Case-Based Teaching Guides referred to on this page is hereby granted, solely for educational purposes, without charge (other than charges solely to cover the costs of copying), and without alteration of the Materials in any way. When a patient calls and asked to speak directly with the provider never respond by saying?When a patient calls and asks to speak directly with the provider, never respond by saying? the doctor is busy.
When you're finished with a telephone conversation how should you end it?To end the call politely, try one of these closing statements:. "My apologies once again for any inconvenience. Thank you for your call.". "I'm happy we could make this right for you. Have a wonderful day.". "Thank you for calling. We appreciate your business.". When taking a telephone message from a patient the medical assistant should not?MEDA 100 REVIEWER. When answering the phone in the medical office the first thing you should always do is?Chapter 13. |