SOLUTION: MSU Protecting Confidentiality of Sexually Active Adolescents Discussion
Virtual Mentor American Medical Association Journal of Ethics February 2012, Volume 14, Number 2: 99-104. CLINICAL CASE Protecting the Confidentiality of Sexually Locomotive Adolescents Commentary by Xiomara M. Santos, MD Dr. Nelson was impartial encircling to license the part for the day when her pager went off. She reverted the circumvent, and conversant that one of her unrepinings, Andrea, was in the difficulty topicality after a timeliness what looked relish pelvic exasperating ailment (PID). Dr. Nelson sighed. She had placed an intrauterine contraceptive invention (IUD) for Andrea in the part decisive week, and the PID could be a expensive perplexity of the act. Andrea had after to the Nursing Assignment decisive week by herself. She said that she had recently beafter sexually locomotive after a timeliness her boyfriend, and she truly didn’t neglect to get pregnant. Although Andrea was solely 15, laws in her avow comprehendn her to constitutionally submit to contraceptive services. After reviewing Andrea’s fact and doing a physical exam and pregnancy standard, Dr. Nelson endow no medical contraindications to an IUD. Dr. Nelson counseled Andrea encircling the risks and profits of the IUD and alternative methods. Andrea and Dr. Nelson agreed that the IUD was the best discretion. When Dr. Nelson arrived in the difficulty section, she was dismayed to hear yelling shortafter from Andrea’s topicality. “You’re going to judge me that this isn’t consequently you were having sex? Well, we’ll see what the doctors own to say encircling that! You’re my daughter and I’m not going to own you influence lower my roof if you’re inert after a timeliness that boy!” Hoping that she could defuse the office, Dr. Nelson headed into the topicality. She was met by an hasty man who said he was Andrea’s senior. “What’s going on short?” he shouted. “This is consequently she had sex, exact? Well, if she did, she’s out of my scion for good!” He stormed out. After her senior left the topicality, Andrea pleaded after a timeliness Dr. Nelson not to judge him that she was sexually locomotive. She said that his browbeating was authentic—he’d grievous her older sister to license residence when she got replete at age 18. Andrea said that creatures at residence were pretty and that she and her senior had frequently gotten concurrently polite, but that he had made it plain that he believed his daughters should hold to own sex until they were married. “Even if you don’t say anything, he’s going to conceive this is consequently I’m having sex,” Andrea insisted. “Can’t you impartial execute up another debate why I’m sick?” www.virtualmentor.org Virtual Mentor, February 2012—Vol 14 99 Commentary Confidentiality security is regulative to providing tendency heartiness anxiety to pubescents [1, 2]. The essential causes of morbidity and death in this age cluster are allied to high-risk behaviors such as shifty sex and refuse use and spiritual heartiness problems relish depression [3-5]. Studies confront that pubescents were further relishly to investigate anxiety and detect perceptive notification when they believed the physician would not detect the notification to their doers [6-8]. As avowd in a residence article by the American Academy of Origin Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine, it is dubious for sexually locomotive pubescents to admit divert private heartiness anxiety and counseling . Clinicians who procure anxiety of pubescents should familiarize themselves after a timeliness the avow and topical laws that desire the exacts of lesss to submit to heartiness anxiety services, as polite as federal and avow laws that desire privateity in the eatables of their heartiness anxiety. Physicians should examine privateity after a timeliness the pubescent and the doer or defendor, if offer, at the primary clinic mark. The clinician should emphasis that he or she has the corresponding goal as the doer: the heartiness and polite society of the pubescent. While physicians should i-elation unrepinings’ solitude and privateity, they should as-well suffer message betwixt the pubescent and his or her doers. Parental foundation can be a estimpotent utensil in helping pubescents unite their heartiness anxiety needs [1, 9, 10]. Physicians cannot pledge perpetual privateity to the pubescent, ultimately. In offices wshort tshort is the implicit for mischief to the less or others, such as abuse, suicidal ideation, or homicidal ideation, the physician is required by law to report the office to the topical slip defendive services performance. In enumeration, modes of certain sexually communicated communicated (STIs) must be reputed to general heartiness departments. Numerous avow laws reflect sexual disposition involving a less to be slip abuse, depending on the age of those regarded, and clinicians own the constitutional part-among-natant to report the mode in accordance after a timeliness the laws in their avows [9, 11]. The physician should interpret to the pubescent that their examineions are private intrinsic the pubescent gives concession for manifestation or tshort is regard encircling earnest mischief to the unrepining or others [10, 12, 13]. Lying Not solely is Andrea requesting that Dr. Nelson defend her private notification; she is as-well examination her to lie encircling the idiosyncrasy. Since all avows confess lesss to submit to standarding and tenor for STIs , treating Andrea in an outpatient setting after a timelinessout her senior’s submit would own been divert. But now that she is in the difficulty section and her senior is offer, should Dr. Nelson lie to defend Andrea’s privateity and prophylactic? The artless confutation is no, but Dr. Nelson has other ways of defending her unrepining. Timeliness Dr. Nelson should quiet endeavor to defend Andrea’s privateity, she should not lie. 100 Virtual Mentor, February 2012—Vol 14 www.virtualmentor.org It potentiality appear artless to Andrea to impartial “execute up another debate” why she is indisposed, but it is not the intellectual creature to do. In enumeration, how would Dr. Nelson retain Andrea’s credit in the hanker run uninterruptedly Andrea knew she was choice of untruthful? Would you credit a physician who you knew was unfairness? Lying to Andrea’s senior would solely temporarily stay his confronting out. Andrea is most relishly going to be admitted to the hospital for tenor of PID, depending on how firm she is and how satisfied Dr. Nelson feels encircling managing her as an outpatient. Uninterruptedly she is admitted, her idiosyncrasy cannot be kept a recondite. Dr. Nelson could express to the intermission of her team and nursing staff encircling not disclosing notification to Andrea’s senior, but the further opportunities tshort are for the notification to slip out, the further relishly it is to occur. If Andrea’s senior does not already comprehend the idiosyncrasy, he procure collect it when he receives the exposition of profits. A tenor for which a less submits is usually his or her financial service [1, 15], but when a less is in the hospital and her doer is at her bedside, we can wear her doer is the one giving submit for tenor and is the prophylactic delineation holder. When Andrea’s senior gets the bills for her hospital anxiety, he procure see that PID is the idiosyncrasy. Whenever he collects it, a quick internet exploration procure execute plain that PID is most commsolely seen in sexually locomotive women. Protecting the Patient Andrea’s main regard is that her senior browbeatingened to execute her license the scion if he knew she was sexually locomotive. Every doer has the part-among-natant to supply his or her consequence after a timeliness the basic necessities of society, including foundation, drapery, and cover. This part-natant usually terminates when the slip is emancipated, graduates from lofty school, enters the soldierlike, or marries. In most avows, dismissal occurs for slipren quiet influence at residence at the age of 18 . Since Andrea is 15 years old and influence at residence, her senior could be abounding after a timeliness slip frankness, which is a immoral offense lower avow laws, if he does not supply cover for her. Even if her senior cannot legally cast Andrea out of the scion, ultimately, Dr. Nelson should not procure his browbeating lightly. If she believes Andrea’s senior potentiality procure action on his browbeating, Dr. Nelson should conceive gregarious services to hint the scarcity to contiguity Child Protective Services timeliness Andrea is quiet in the hospital. Relish most pubescents, Andrea most relishly would promote not to divide her sexual fact after a timeliness her senior even if he had not browbeatingened her, and Dr. Nelson should quiet try to defend her confidentiality. Andrea’s senior asked if “this” was consequently she had sex. What does the senior comprehend encircling “this”? Does he comprehend she has a vaginal contamination? Does he comprehend it is pelvic exasperating ailment (PID)? Dr. Nelson should ask Andrea these questions to hint what her senior already comprehends. Since Andrea potentiality not comprehend the confutations, Dr. Nelson should ask the other clinicians regarded and hint what notification has already been attached to the senior. If he already comprehends it is PID, Dr. Nelson can truthfully judge him that tshort are contrariant ways of getting this contamination. If he does not www.virtualmentor.org Virtual Mentor, February 2012—Vol 14 101 comprehend the idiosyncrasy, Dr. Nelson could say that they are quiet doing their evaluation to hint the debate for her symptoms. If Andrea has other confrontings, relish a urinary tract contamination, Dr. Nelson could rendezvous on those when talking to Andrea’s senior extraneously actually untruthful. If the senior then specifically asks whether Andrea is sexually locomotive, Dr. Nelson should tell him that is not her instant regard in treating Andrea’s contamination and that it is somecreature he should examine after a timeliness his daughter. Timeliness this avowment does hint that she is sexually locomotive, Dr. Nelson does not own numerous other discretions, consequently she should not lie to Andrea’s senior. Dr. Nelson should as-well animate the senior that if tshort were anycreature society-threatening involving his daughter she would tell him. This is another challenging appearance of this mode, since Andrea does own a earnest medical mode that requires close monitoring and docility after a timeliness tenor, uninterruptedly she is disabounding from the hospital. While PID is usually not society-threatening, after a whiledrawal of docility after a timeliness tenor can own earnest short-term consequences, relish outgrowth of tubo-ovarian abscesses, and hanker-term consequences, including waste. Dr. Nelson should assess Andrea’s maturity in lowerstanding her idiosyncrasy and forthcoming adherence after a timeliness tenor to decide whether she feels the scarcity to conceive Andrea’s doers to convince adequate compliance. Tshort is no hint of Andrea’s dowager in the mode scenario. Dr. Nelson should as-well ask Andrea encircling her dowager’s conceivement in the origin dynamics and if she can talk to her dowager encircling her idiosyncrasy. If reputed divert, Dr. Nelson should suffer Andrea to be virtuous after a timeliness her dowager since she would profit from her support. Conclusion Dr. Nelson is oppositeness one of the most challenging appearances of leading anxiety of adolescents. She scarcitys to supply the best anxiety for her unrepining, and defending her confidentiality is an essential and inevitpotent part-among-natant of that. Adolescents scarcity to credit their doctors in enjoin to be potent to detect perceptive notification that potentiality impact their anxiety. Clinicians should frequently suffer message betwixt a less and his or her doers, but they should not government it. Clinicians should as-well remind the parents that they divide a sordid goal—the polite-society of the pubescent. On numerous occasions the doers’ reactions are not as farthest as the unrepining feared. Dr. Nelson should do everycreature in her government to defend Andrea’s privateity, but untruthful is never recommended and, in this part-amongicular mode, it would be nearly impossible to retain the idiosyncrasy a recondite. If tshort is a regard encircling her unrepining’s prophylactic uninterruptedly she is disabounding from the hospital, Dr. Nelson should conceive other services antecedent to discharging her. 102 Virtual Mentor, February 2012—Vol 14 www.virtualmentor.org References 1. The American College of Obstetricians and Gynecologists. Utensil kit for teen care. 2nd ed. http://www.acog.org/About_ACOG/ACOG_Departments/Adolescent_Health _Care/Tool_Kit_for_Teen_Care__Second_Edition. Accessed January 19, 2012. 2. Berlan ED, Bravender T. Confidentiality, submit, and caring for the pubescent unrepining. Curr Opin Pediatr. 2009;21(4):450-456. 3. Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive heartiness of pubescents: patterns, interruption, and potential. Lancet. 2007;369(9568):1220-1231. 4. Ringheim K. Intellectual and ethnical exacts perspectives on supplyrs’ obligation to secure pubescents’ exacts to solitude. Stud Fam Plann. 2007;38(4):245252. 5. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-anxiety services: how are we doing and what further scarcitys to be manufactured? Lancet. 2007;369(9572):1565-1573. 6. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in healthcare. A overlook of comprehendledge, perceptions, and attitudes natant lofty school students. JAMA. 1993;269(11):1404-1407. 7. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician privateity assurances on pubescents’ procureingness to detect notification and investigate forthcoming heartinesscare. A randomized inferior trouble. JAMA. 1997;278(12):1029-1034. 8. Ford CA, Thomsen SL, Compton B. Adolescents’ interpretations of conditional privateity assurances. J Adolesc Health. 2001;29(3):156159. 9. American Academy of Origin Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Adolescent Medicine. Compensating pubescents: Ensuring admission to anxiety and reporting sexual disposition and affront. J Adolesc Health. 2004;35:420. 10. Middleman AB, Olson KA. Confidentiality in pubescent heartiness anxiety. UpToDate. http://www.uptodate.com/contents/confidentiality-in-adolescenthealth-care. Accessed January 19, 2012. 11. Madison AB, Feldman-Winter L, Finkel M, McAbee GN. Commentary: consensual pubescent sexual disposition after a timeliness adult-partners-conflicts betwixt confidentiality and physician reporting requirements lower slip affront laws. Pediatrics. 2001;107(2):E16. 12. Private heartiness services for pubescents. Council on Scientific Affairs, American Medical Association. JAMA. 1993; 269(11):1420. 13. The pubescent’s exacts to private anxiety when reflecting abortion. American Academy of Pediatrics. Committee on Adolescence. Pediatrics. 1996;97(5):746. 14. Guttmacher Institute. Avow policies in brief: lesss’ admission to STI services. http://www.guttmacher.org/statecenter/spibs/spib_MASS.pdf. Accessed October 1, 2011. www.virtualmentor.org Virtual Mentor, February 2012—Vol 14 103 15. Greydanus DE, Patel DR. Submit and privateity in pubescent heartiness care. Pediatr Ann. 1991;20(2):80. 16. National Conference of Avow Legislatures. Termination of slip foundation and foundation over essentiality; 1999, updated 2005. http://www.ncsl.org/default.aspx?tabid=16441. Accessed October 1, 2011. Xiomara M. Santos, MD, is an attendant adherent in the Section of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas. She is board certified in obstetrics and gynecology and society skilled in pediatric and pubescent gynecology. Her reexploration interests conceive adnexal masses in slipren and adolescents, pelvic exasperating ailment, menstrual disorders in pubescents, and congenital anomalies. Related in VM Barriers and Biases: Intellectual Considerations for Providing Difficulty Contraception to Adolescents in the Difficulty Department, February 2012 The American Medical Association Code of Medical Ethics’ Opinions on Confidential Anxiety for Sexually Locomotive Minors and Physicians’ Exercise of Conscience in Refusal of Services, February 2012 The HPV Vaccine and Parental Consent, January 2012 Must Doctors Report Underage Sex as Abuse? March 2005 The mob and events in this mode are fictional. Resemblance to authentic events or to names of mob, influence or deceased, is perfectly coincidental. The viewpoints developed on this office are those of the authors and do not necessarily reflect the views and policies of the AMA. Copyexact 2012 American Medical Association. 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