Weighing Confidentiality With Adolescent Patients

HILTON HEAD ISLAND, S.C. -- Adolescent patients and their parents deserve a straightforward explanation about a patient's right to confidentiality and the circumstances under which that confidentiality may be breached, Dr. Tomas Silber said at a pediatric meeting sponsored by Contemporary Forums.

A written or verbal contract can help define confidentiality and establish the patient's trust, said Dr. Silber, director of the Office of Ethics at Children's National Medical Center in Washington, D.C.

The contract should be age appropriate. A younger adolescent can simply be told that whatever is discussed with the physician will be kept private unless something happens to endanger the child's health. An older adolescent can be told about the specific circumstances under which confidentiality may be breached, such as when a patient has suicidal or homicidal tendencies, when physical or sexual abuse is suspected, and when a patient has a dangerous condition such as an eating disorder' or substance abuse problem.

"It has been shown that explaining this will not eliminate these issues from a conversation with the physician. These matters will be revealed to you anyway," said Dr. Silber, also professor of pediatrics at George Washington University in Washington.

Sometimes, adolescents assume that because you are discussing confidentiality you must think they have secrets. If patients appear offended by the fact that you have brought up the subject of confidentiality, it might help to explain that the discussion will be confidential even if they do not mind their parents knowing about it, he noted.

If you determine that confidentiality should be breached, involve patients in sharing information. Find out first if patients wish to share the information with their parents in private or with you present or if they want you to discuss it with their parents.

Keep in mind that parents also have some right to confidentiality. Sometimes parents want to discuss matters relevant to their child's health without the child present. This should be minimized to avoid making the patient feel excluded, should be limited to the early stages of treatment if possible, and should be seen as an opportunity to help the family improve communication skills, but any such conversations should be kept confidential.

As for when an adolescent patient is sufficiently mature to consent to basic medical care and to be entitled to confidentiality, physicians have the legal authority to make that determination. It should be based on their own assessment of whether the patient can understand the medical information presented. This generally occurs at about age 14, in his experience.

Courts have repeatedly upheld this "mature minor concept," Dr. Silber said.

When a patient is deemed to be a mature minor, parents do not have the right to insist on knowing, for example, whether their child is sexually active, uses drugs, or has been prescribed birth control pills.

State laws vary on what types of care a minor has the right to seek without parental permission. In some states, the right depends on age, emancipation, or marital status. In other states, the right is based on the type of service. Pregnancy-related care, treatment for sexually transmitted diseases, and treatment for substance abuse are examples of types of care that may be protected. Know the state laws that may affect your practice, Dr. Silber said.