Legal and Ethical Issues in Adolescent Medicine

1. Legal and Ethical Issues in Adolescent Medicine Marcia J. Nackenson, MD Section of Adolescent Medicine Dept. of Pediatrics New York Medical College

2. Outline Legal Issues 1. Consent 2. Confidentiality 3. Payment Ethical Issues 1. Principles of Autonomy and Beneficence 2. Approach to an Ethical Dilemma

3. 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).

4. Exceptions to Parental Consent 1. General Exceptions 2. Exceptions Based on Status (Who you are) 3. Exceptions Based on Situation (What’s happening)

5. General Exceptions • Courts • Dept. of Social Services • Foster Parents • Emergencies

6. Exceptions Based on Status • Married Minors • Minors who are Parents • Pregnant • Armed Forces • Emancipated • Mature Minor

7. Emancipated Minors • Legally: Renunciation of parental rights to a child. • Also: Married, Parent, Military • Living independently, financially independent. • Courts unclear, few cases.

8. 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.

9. Mature Minor Issues • Rarely invoked • Little case law • Does maturity equal agreeing with the doctor?

10. Exceptions Based on Situation • Vaccinations • Pregnancy • Contraception • Abortion • STD’s • HIV • Drug and Alcohol • Mental Health

11. Consent for Vaccination • Parent or legal guardian • Grandparent • Adult sibling • Adult aunt or uncle • Any adult with written authorization

12. 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

13. Contraception • No parental consent or notification required • No age limit • U.S. Supreme Court upheld

14. Abortion • State laws vary • New York State: No parental consent or notification required • No age limit

15. STDs • No parental consent required for testing or treatment • Dept. of Health notification mandatory • Partners may be informed of exposure anonymously

16. 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

17. Drug and Alcohol Treatment • Outpatient: Adol may consent • Inpatient: Adol may consent if: • Parental involvement may be detrimental or • Parents refuse consent

18. 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

19. Confidentiality • Care that an adol may consent to is confidential. • Encourages an adol to seek care, esp sensitive issues. • Not intended to excluded parents.

20. 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

21. HIPAAHealth 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.

22. 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 - Medicaid PCAP

23. Statutory RapeNew York State • Male any age, female < 18, misdemeanor of sexual misconduct • Defendant >21, minor <17 • Defendant >18, minor <14 • Male any age, minor <11

24. 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.

25. Physicians’ Role in Statutory RapeMy 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

26. 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

27. Ethical Issues • Autonomy takes precedence over beneficence if the adol is mature. • Paternalism - interfering with the liberty of another for their own good.

28. 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.

29. 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.

30. 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.

31. Case #1 Follow-up • Maturity demonstrated by using condoms, seeking contraception. • Regardless of maturity, NY State law provides for confidential contraceptive care.

32. 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.

33. 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 Statement (1996) rejects involuntary screening

34. 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?

35. 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.

36. 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.

37. 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 medication and therapy.

38. 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 apt for them.

39. 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 of cycle, but still concerned about rehab.

40. 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.