Instructor's Guide: Confidentiality and Adolescents

Case Summary

A 14-year-old accompanied by her mother presents with complaints of nausea and vomiting for two weeks. After her mother leaves the room, she admits to being sexually active, and tells you that she has had unprotected intercourse recently with her boyfriend and missed a period. Her parents do not know she is sexually active, and she does not want her mother to know that a pregnancy test is being done or the result of that test. Pregnancy test comes back positive.

• Do you disclose the test results to the patient’s mother?
• Do you disclose the test results to the patient first?
• How will you get the mother to leave the room to disclose results?
• What if the mother asks about test results?

Alternative Cases

1. A 16-year-old girl sees her pediatrician without her parents’ knowledge. She wants your assurance that everything will remain confidential and she is reassured by your response.
   She then discloses that she has been having a sexual affair with her stepfather. There has been no force or threat on his part. She believes she has been the provocative one. When the physician says they need family therapy and he is under legal obligation to report this to social services, the girl insists that he do neither and that she would not have told him anything had she known. Would it change anything if the boyfriend was a 21-year-old? 18- or 16-year-old?
2. You are caring for a 17-year-old male who is HIV-positive. He relates that he is having unprotected intercourse with his girlfriend who is unaware of his HIV status. As you continue to discuss this situation and the risk it poses to his girlfriend, he states that he has no intention of changing his behavior or revealing his HIV status to his girlfriend. Further discussion fails to result in changing his mind on this point. What would you do?
3. The police bring in a 15 year-old street kid for an evaluation. During the course of your exam, you notice a foreign body in the ear canal that turns out to be foil-wrapped rock cocaine. What would you do?

Learning Objectives

1. Discuss the basis of the duty of medical confidentiality and its application to the adolescent patient
2. Identify situations in which breaking confidentiality is justified and the conditions that must be met to break confidentiality
3. Recognize the physician’s duty to the patient when confidentiality is violated
4. Identify threats to the patient’s confidentiality (i.e., the bill which is to be sent to parents)
5. Discuss whether deception is justified to maintain confidentiality and any alternatives to the use of deception

Suggested Reading for Instructor

Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: a survey of knowedge, perceptions, and attitudes among high school students. JAMA. 1993;269:1404-1407.

Geiderman JM, Moskop JC, Derse AR. Privacy and confidentiality in emergency medicine: obligations and challenges. Emerg Med Clin N Am. 2006;24:633-656.

Reddy D, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA. 2002;288:710-714.

Siegler M. Confidentiality in medicine — a decrepit concept. New Engl J Med. 1982;307:1518-1521.

Thrall J, McClosky L, Ettner S, et al. Confidentiality and adolescents’ use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med. 2000;154:885-892.

Confidentiality and Adolescents

1. Instructor's Guide2. Student's Guide3. Case Discussion

This instructor’s guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's.

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