Transcript Legal and Ethical Issues in Adolescent Medicine

Legal and Ethical Issues in
Adolescent Medicine
Marcia J. Nackenson, MD
Section of Adolescent Medicine
Dept. of Pediatrics
New York Medical College
Outline
Legal Issues
1. Consent
2. Confidentiality
3. Payment
Ethical Issues
1. Principles of Autonomy and
Beneficence
2. Approach to an Ethical Dilemma
Informed Consent
Any patient must understand:
1. His condition
2. Risks and benefits of proposed
treatment
3. Alternatives
In general, parents must consent
for care for minors (< 18 years).
Exceptions to Parental
Consent
1. General Exceptions
2. Exceptions Based on Status
(Who you are)
3. Exceptions Based on Situation
(What’s happening)
General Exceptions

Courts

Dept. of Social Services

Foster Parents

Emergencies
Exceptions Based on
Status






Married Minors
Minors who are Parents
Pregnant
Armed Forces
Emancipated
Mature Minor
Emancipated Minors



Legally: Renunciation of parental
rights to
a child.
Also: Married, Parent, Military
Living independently, financially
independent.
– Courts unclear, few cases.
Mature Minors


Can understand the risks and benefits
of what he is consenting to and its
alternatives.
Must consider developmental stage:
– Early adol. - concrete, conformist.
– Middle adol. - inc. abstraction, “now”
mentality, body image issues.
– Late adol. - personal values.
Mature Minor Issues

Rarely invoked

Little case law

Does maturity equal agreeing with
the doctor?
Exceptions Based on
Situation








Vaccinations
Pregnancy
Contraception
Abortion
STD’s
HIV
Drug and Alcohol
Mental Health
Consent for Vaccination





Parent or legal guardian
Grandparent
Adult sibling
Adult aunt or uncle
Any adult with written authorization
Pregnancy



Medical, dental, and hospital care
relating to prenatal care - interpreted
loosely.
Includes labor & delivery, caesareans.
Medicaid/Prenatal Care Assistance
Program (PCAP) - based only on adol.
income
Contraception

No parental consent or notification
required

No age limit

U.S. Supreme Court upheld
Abortion



State laws vary
New York State: No parental
consent or notification required
No age limit
STDs



No parental consent required for
testing or treatment
Dept. of Health notification
mandatory
Partners may be informed of
exposure anonymously
HIV/AIDS





Different laws from other STDs
Minor has the right to consent or to
refuse HIV testing
Option of anonymous testing
Treatment - laws less clear, most allow
minor to consent
But - foster care agencies or parents
may be informed
Drug and Alcohol
Treatment


Outpatient: Adol may consent
Inpatient: Adol may consent if:
–Parental involvement may be
detrimental or
–Parents refuse consent
Mental Health Services
1. Outpatient: Adol may consent if:
a. Parental involvement may be
detrimental or
b. Parents refuse consent
2. Inpatient:
a. Under 16 yrs, parental consent
required
b. Over 16 yrs, adol may seek
treatment
Confidentiality
 Care
that an adol may consent
to is confidential.
 Encourages an adol to seek
care, esp sensitive issues.
 Not intended to excluded
parents.
Limits to Confidentiality
Intent to harm oneself or another:
Suicidal or homicidal
ideation
 Legally mandated reporting:
Child abuse, sexual abuse
Reportable diseases
 Professionals at the same facility
may share information

HIPAA
Health Insurance Portability
and Accountability Act
State law governs in the area of
parents and minors.
 Licensed health care provider may
exercise discretion concerning
privacy as long as consistent with
such state laws.

Payment


Parents not obligated to pay when
minors consent for their own health
care.
Alternative Health Care Funding:
a. Private Insurance
EOBs, lab bills
Managed care - pre-paid
b. Cash, Medicaid, Child
Health Plus
c. Pregnant -
Statutory Rape
New York State
Male any age, female < 18,
misdemeanor of sexual
misconduct
 Defendant >21, minor <17
 Defendant >18, minor <14
 Male any age, minor <11

Mandatory Reporting of
Child Sexual Abuse
Parent or other responsible for
minor commits or allows to be
committed a sex offense.
 Not adolescents having
consensual sex, only parental
knowledge of forced sex.

Physicians’ Role in Statutory
Rape
My Recommendations




Is the adolescent harmed?
Use common sense.
We are not law enforcement agents.
Adolescent pregnancies
21% of births to unmarried minors
have
fathers >5 yrs older
Ethical Principals
1. Autonomy
- Respects for persons
- Those with diminished automony are
entitled to protection
- Varies with maturity for adol.
2. Beneficence
-Requirement to do the most good for
our patients
Ethical Issues
 Autonomy
takes precedence
over beneficence if the adol
is mature.
 Paternalism - interfering
with the liberty of another
for their own good.
Principals for an Ethical
Dilemna


The more certain a physician is of the
benefit of the treatment, the more
compelling the need to override
autonomy or parental rights.
With non-compliance,(parents agree)
the more certain the benefit of
treatment, the more justified is judicial
interference.
Approach to an Ethical
Dilemna



Try to reconcile the views of patient
and parent.
Consult hospital Ethics Committees.
Avoid withholding life-saving treatment
without a court order if the parents
are not in agreement.
Case #1

A 16 year old female who has
been in a monogamous sexual
relationship (using condoms) for
one year comes to you requesting
oral contraceptives. She does not
want her parents to know.
Case #1 Follow-up


Maturity demonstrated by using
condoms, seeking contraception.
Regardless of maturity, NY State law
provides for confidential contraceptive
care.
Case #2

A 16 year old male is brought in by his
mother who privately asks you to do a
urine drug screen because he has
been hanging out with the “wrong”
kids, breaking curfew, and his grades
have been dropping. He believes he
has come for a sports physical.
Case #2 Follow-up




Much more information is gained by a
private history than a one-time urine
test
If negative, how often will the parent
return for another test?
If positive, your deception will likely
destroy your relationship with the
patient and any chance of helping him.
AAP Comm.on Substance Abuse
Case #3


A father brings in his 15 year old
daughter to be examined to see if she
is still a virgin.
Does it change the situation if she
agrees to the exam?
Case #3 Follow-up




Physical exam is not diagnostic.
How often would they return?
Relationship must be explored to
determine why he is suspicious and
why he does not accept her word.
Communication is the issue.
Case #4

A 16 year male who is clinically
depressed tells you he has thoughts of
going to his school and shooting
people. He does not have a gun and
does not have access to one. He is not
currently in psychiatric care.
Case #4 Follow-up


Patient was informed that
confidentiality would be broken.
I called the legal guardian and
informed her of the situation and
insisted that the patient see a
psychiatrist the next day or Child
Protective Services would be called.
She complied and he was successfully
treated for his depression with
Case #5

A 16 year old pregnant girl is referred
to you by her parents for counseling.
A 31 yr old is the father of the baby.
A. A 31 yr old police officer
assigned to
patrol her school is
the father.
He convinces her to drop out.
B. And the girl’s parents have
purchased
and furnished an
Case #6



A 16 yr old female resident of a drug
rehab facility presents for routine gyn
exam. LMP was 6 days previously.
She reports unprotected intercourse 1
day prior.
Offered emergency contraception, but
will be kicked out of rehab for sexual
activity.
Suggested starting OCPs since day 6
Case #6 cont.


Offered Depo-Provera as option, but
refused, “hates needles”.
After much discussion with patient and
staff, prescribed OCPs on the premise
that the rehab facility would be
obliged to fill a prescription, without
the right to know the medical
indication for it.