By: Adam Hunter, MD student at University of North Carolina at Chapel Hill
In the American medical system, full moral status is assigned to competent adults. Beauchamp and Childress’s ethical principles of beneficence, non-maleficence, justice, and respect for autonomy define how competent patients should be treated (1). A case illustration helps to demonstrate the principles at conflict in disclosing sensitive information of minors.
Kevin is a 14-year-old male visiting his long time pediatric physician, Dr. Andrews, with the complaint of a possible sexually transmitted disease. As is his practice, Dr. Andrews began addressing sexuality, risky behaviors, peer pressure, and other topics relevant to his teen patients with Kevin a few years ago. When Dr. Andrews begins these interviews with his teen patients, he also prepares parents, explaining his view about how the newly confidential physician-patient relationship benefits patients. Until this visit, Kevin has denied any sexual activity with others.
During this visit, Kevin expresses to Dr. Andrews that he has been having sex with multiple partners while “hooking up with friends” after school. He and his friends have made a habit of organizing these “get-togethers” in the afternoons before their parents return home from work. He is somewhat vague about whether they are practicing “safer” sex and about alcohol use that may or may not be involved in the gatherings, but he indicates that the others invited are all “about his age” and both male and female. Kevin seems uncomfortable with the practices he has been engaging in but asks Dr. Andrews not to share the divulged information with his parents. Dr. Andrews has a strong sense that Kevin wants someone in a position of authority to help him deal with these peer-pressured behaviors. Furthermore, in his experience, teen high-risk behaviors are most effectively addressed in early onset. As Dr. Andrews has seen Kevin since he was an infant, he is very familiar with Kevin’s parents and feels that they would be both supportive and proactive in helping him handle the peer pressure and in arranging his afternoons to avoid participating in activities with potential serious psychological and physical health consequences. While Dr. Andrews can help Kevin by offering guidance and referral to additional counseling, he also sees Kevin much more rarely than do Kevin’s own parents who could monitor the situation closely and be more proactive in their approach. Later that afternoon, Kevin’s mother calls Dr. Andrews and says, “I know that your visits with Kevin are confidential now that he has reached his teen years, but I’ve been worried about his mood at home. Is there anything I should know?” What should Dr. Andrews say? Generally, how should Dr. Andrews handle this situation with Kevin?
In summary, 14-year-old Kevin presents to his long-time physician (Dr. Andrews) with a sexually transmitted infection (STI) and admits to routinely having unprotected sex with multiple partners after school. Kevin seeks treatment and guidance but asks the doctor not to share his diagnosis and its cause with his parents. Aware of Kevin’s mood changes at home, Kevin’s mother requests information about his well-being from Dr. Andrews, who believes Kevin needs help managing peer pressure but is unsure what he can ethically disclose. Casuistic analysis of the moral issues at stake, the effects of disclosure on the patient-physician relationship, and the principles of justice, beneficence, and non-maleficence will determine the best solution to this dilemma. In this case, a virtuously loyal and honest physician would prioritize the patient’s wishes, and Dr. Andrews should disclose neither Kevin’s sexual history nor his diagnosis to Kevin’s mother without Kevin’s consent. The best approach is for Dr. Andrews to engage Kevin in ongoing dialogue about his sexual health, social pressure, and the possibility for open communication with his parents. This will require an adaptable methodology to account for legal and public health concerns that may arise.
Here, pertinent considerations include Kevin’s status as a minor, potential coercion into unwanted sexual activity, fair distribution of STI prophylaxis to his partner(s), beneficent medical treatment, the possibility of a confidentiality breach, and Kevin’s autonomy. Legal concerns involve underage drinking, non-consensual sex, and treatment and reporting of STIs in minors. An abbreviated list of the most salient principles includes non-maleficence and respect for autonomy, and these will be extensively considered.
Dr. Andrews’s established precedent of confidential patient-physician relationships with teenagers reinforces Kevin’s medical consideration as an adult. According to North Carolina law, there is no set age at which minors acquire decisional capacity regarding medical care for sexual health issues, and “as part of normal development, most minor children acquire decisional capacity that is similar to that of an adult at some point before the age of 18” (p. 1, 2). Indeed, Applebaum’s criteria for competence include: ability to communicate choices, understand relevant information, comprehend the nature of a decision and its consequences, and manipulate information rationally (3). Furthermore, for minors with established decisional capacity, there is no legal stipulation to inform parents of their children’s treatment for STIs (2). Since Dr. Andrews previously affirmed Kevin’s decisional capacity when he initiated their confidential relationship, and explained this to Kevin’s mother, he cannot ethically breach confidentiality without a measurable decrease in Kevin’s mental faculties or significant risk for harm.
If Kevin qualifies for full moral status, he is entitled to seek treatment for his STI. It is Dr. Andrews’s professional obligation as a physician to educate and counsel Kevin about risky behaviors and peer pressure, as he should for all of his teenage patients. If Dr. Andrews has a “strong sense that Kevin wants someone in a position of authority” to teach him about healthy sexual relationships, it is Dr. Andrews’s job as a loyal and trusted physician to schedule more frequent visits with Kevin and to monitor progress towards meeting his social and sexual health goals. After all, this is what Dr. Andrews would do for any other patient with a chronic health concern.
Dr. Andrews’s behavior is likewise governed by the principle of non-maleficence, and he should recognize the potential harm resultant from negligence to follow up with Kevin. In addition, disclosure of confidential information to Kevin’s mother without Kevin’s autonomous consent could destroy their patient-physician relationship. At this vulnerable time in Kevin’s life, when he is unwilling to divulge his after school behavior to his mother, and seems to have a tenuous relationship with his friends, Dr. Andrews should act as a resource for emotional and medical support. Aristotle’s virtuous doctor is predisposed to truthfulness, compassion, and loyalty that transcend the limitations of consequence and duty (4). The principled and virtuous doctor keeps his or her patients’ secrets.
The philosophies of Mill and Kant merit consideration. The Kantian imperative is to treat Kevin as an end in himself, rather than as a utility by which to secure the sexual health of his peers. A comparison clarifies this point. In many public places, cigarette smoking – and subsequent uncontrolled transmission of lethal toxins in secondhand smoke – is not punishable by law, nor does it mandate physicians to involuntarily commit, treat, or report patients who continue smoking against medical advice. Likewise, if Dr. Andrews prescribes to the Kantian ethos, the duty to promote Kevin’s partners’ sexual health via disclosure to Kevin’s mother does not override his moral obligation to uphold his confidentiality agreement with Kevin.
Mill’s utilitarian approach falls short of attaining ethical preponderance here. Kevin’s peers’ risky sexual behaviors could continue even if his mother intervenes. Rather than prioritizing the health of Kevin’s friends, who fall outside of Dr. Andrews’s purview anyway, Dr. Andrews should treat Kevin, counsel him, and respect his wishes first. With the patient-physician relationship maintained, and Kevin’s autonomy preserved, Dr. Andrews’s moral standing is upheld. There is no guarantee that informing Kevin’s mother will prevent his or his friends’ risky sexual behaviors in the future. Furthermore, his relationship with his doctor, a unique form of social and medical support, would be marred. Disclosing confidential information to Kevin’s mother serves no significant utilitarian purpose.
The arguments for disclosure include, of course, that Kevin is a minor, and his mother needs the information to protect and promote his health. This argument presumes that his mother could stop his unsafe behavior and would teach him to resist peer pressure in non-isolating ways. It also falsely elevates Kevin’s risk to such an extreme that it imposes a moral duty to breach confidentiality. Physicians are obligated to safeguard public health under special circumstances (5), but sexual experimentation among teenagers and the inherent possibility for STI transmission are anecdotally commonplace. Under North Carolina’s General Statutes (§ 90-21.5), minors are allowed to consent for prevention, diagnosis, and treatment of sexually transmitted diseases on their own (6). The law protects Kevin’s right to confidential STI testing and treatment despite his legal status as a minor.
Proponents of disclosure might conclude that because of the potentially non-consensual nature of his sexual experiences, and his current infection, Kevin poses a significant health risk to others. In the spirit of patient centered care, Dr. Andrews’s deontological responsibility to promote his patient’s well-being precludes his role as a protector of public health. Dr. Andrews’s moral, ethical, and virtuous course of action is to prevent STI transmission by protecting his relationship with Kevin, serving as a confidante and counselor, and treating Kevin for his infection. Dr. Andrews should elicit information from Kevin and educate him about safe sex. As a beneficent physician, Dr. Andrews should advocate for behavioral change at every opportunity and educate Kevin about his psychosexual health and the risks he poses to his friends. He is responsible for Kevin’s referral to a specialist or social worker who could help, if those services are needed. If Dr. Andrews believes Kevin’s situation can be best addressed by his mother, he should introduce the need for open communication to Kevin and offer to serve as a mediator for such conversations. However, Dr. Andrews should facilitate communication between Kevin and his mother only when Kevin is ready.
The possibility of productive familial dialogue is not worth betraying Kevin’s trust in his doctor, who alone can test and treat him for his infection. James Dwyer writes that healthcare professionals “are not obligated to speak up when they know that doing so will accomplish nothing” (p. 139, 7). Dr. Andrews cannot be faulted for upholding his standard confidentiality agreement with his patient.
The essential tenet of philosophical reflection on complicated medical cases is that ethics is (and should be) humanizing (8). Teaching Kevin, respecting his wishes, and empowering him to make good decisions about his relationships and behaviors lets him learn from life experience and promotes mutual trust in the patient-physician relationship. He is an end in himself, and he is competent enough to take responsibility for his behavior, with guidance. A virtuous, wise, and compassionate physician would treat the patient-physician relationship with utmost respect.
Adam Hunter is a student at the University of North Carolina School of Medicine. The original version of this essay was written for the Professional Development II course at the University of North Carolina School of Medicine. Students were tasked with writing a response to one of three ethically controversial cases. The text describing the scenario in the case illustration, which involves the divulgence of sensitive information to a minor’s parents, is copied from the assignment document.
References
- Walker, R. L. (2005). Bioethics. In Encyclopedia of Philosophy (598-605).
- Moore, J. (2015). Consent to medical treatment for minor children: Overview of NC law. https://www.sog.unc.edu/sites/www.sog.unc.edu/files/course_materials/Consent%20to%20Medical%20Treatment%20for%20Minor%20Children_0.pdf.
- Napier, S. (2014). When should we not respect a patient’s wish? The Journal of Clinical Ethics, 25(3), 196-206.
- Walker, R. L. (2010). Virtue ethics and medicine. Medical Ethics, 17(3), 1-2.
- North Carolina Medical Board. (2015). Physician’s Guide to Statutory Exceptions to the Duty of Confidentiality. Raleigh, NC.
- North Carolina General Statutes, Chapter 90 Article 1A, § 90-21.5.
- Churchill, L. R., King, N. M. P., & Schenck, D. (2005). Ethics in medicine: An introduction to moral tools and traditions. In The Social Medicine Reader: Volume I (169-185). Durham, NC: Duke University Press.
- Dwyer, J. (2005). Primum non nocere: An ethics of speaking up. In The Social Medicine Reader: Volume I (169-185). Durham, NC: Duke University Press.
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