The Ethics of Pediatric/Adolescent Healthcare

HCR 210 Ethics for the Healthcare Professional The Ethics of Pediatric/Adolescent Healthcare Learning Objectives: • Summarize the ethical principles of human dignity and personal autonomy underlying the health care system's response to mental illness and disability • Understand the unique ethical issues related to pediatric and adolescent health care • Apply ethical decision-making models and principles to the issues surrounding vulnerable members of society Pediatric/Adolescence Values What are some values that adolescence and teenagers seem to have? • ___________________ • ___________________ • ___________________ Pediatric/Adolescence Development • Citizens in the United States are legally considered adults at the age of 18 o Note that this is sometimes different in other countries • The frontal lobes, and more specifically the pre-frontal cortex, do not achieve neuro-maturation (the addition of selective myelination) until early 20s or later • The pre-frontal cortex is responsible for higher level cognition and executive functioning including inhibition, planning, attention, and goal-directed behavior • The connections between the amygdala and frontal lobes also continue into adulthood Pediatric/Adolescence Development Scientifically, this means adolescents are more vulnerable to risky and emotional behaviors. Pediatric/Adolescence Development Current Trends in Health Risk Behaviors Current Trends in Health Risk Behaviors Ethical Considerations Two main issues with adolescent medical care: • Informed consent • Privacy/confidentiality We know that adolescence are vulnerable to high-risk behaviors, but how does this affect autonomy as a principle of bioethics? Do you believe that adolescent should have the ethical and legal right to make decisions regarding their own healthcare and maintain confidentiality? Case Study Until a few months ago, Jason, 16, did well in school and was active in student government. His parents notice that his grades have since deteriorated, he has started skipping school, he has changed his dress and friends, and has been avoiding his family. His mother made an appointment for a checkup and asked your staff to perform a urine drug screen without Jason’s knowledge. You see Jason alone and he denies using substances other than infrequent marijuana use. His physical exam is normal. From this history, appearance, and demeanor, you are worried about drug abuse. What should the pediatrician do? Case Study What should the pediatrician do? A. Listen to the family and perform the drug test on the Jason without letting him know B. Listen to the family but tell Jason what is happening and force him to take the drug test C. Listen to the family but ask the Jason if he is willing to consent to the drug test D. Do not listen to the family and ask Jason what he wants to do Case Study Lucy is a 15 year old female who presents to her pediatrician for a general check up. During the check up, the pediatrician notices that Lucy is nervous and seems to want to ask for something but does not want to ask in front of her parents. The pediatrician asks Lucy’s parents to step out, during which time Lucy admits that she is currently sexually active and she would like to start birth control. Even though the pediatrician suggests that Lucy shares this information with her parents, Lucy is absolutely against it. You know that Lucy will need to be screened for STIs and that her birth control would include a $30 copayment, both of which will likely show up as an Explanation of Benefits in her insurance bill that will go to her parents. What should the pediatrician do? Case Study What should the pediatrician do? A. Tell Lucy that you cannot give her birth control or STIs without her parent’s consent B. Call Lucy’s parent’s back inside and have this discussion together as a family C. Give Lucy the birth control and test for STIs on the condition that she tells her parents on her own D. Give Lucy the birth control and test for STIs without letting the parents know Ethical Considerations We need to know the laws. Adolescent Healthcare Laws • Every state has different laws • Generally, these laws will regulate in which circumstances an adolescent may consent to medical care and when that care is confidential o Some states may allow physicians to notify parents however do not require it o Differences in the age at which an adolescent may consent for medical testing o Differences in what medical services adolescence are able provide consent to • In addition, there are federal laws which also may affect consent and privacy HIPAA *Disclaimer: Laws are subject to change and may not reflect current statutes. This is not intended to serve as legal or medical advice. • Health Insurance Portability and Accountability Act of 1996 o Parents do not necessarily have the rights to their children’s health information if the child is able to legally consent to healthcare o Who may have access to an adolescent’s medical record is also dependent on state laws if applicable Arizona Minor Healthcare Laws *Disclaimer: Laws are subject to change and may not reflect current statutes. This is not intended to serve as legal or medical advice. “Since there is no single Arizona statute that deals specifically with the confidentiality of a minor’s medical record on the issue of parental access, the clinician can use his/her professional judgment regarding release of records, or at least the confidential aspect, to parents.” However, as healthcare providers, you have a legal duty to report to a peace officer or the Department of Safety if your observation or examination of a minor discloses reasonable grounds for suspicion of abuse, exploitation, or neglect. Arizona Minor Healthcare Laws *Disclaimer: Laws are subject to change and may not reflect current statutes. This is not intended to serve as legal or medical advice. “Specific consent is needed when health care providers are going to penetrate the skin, insert or implant something in the body, use radiation, or do surgery or comparable invasive procedures which interfere with body tissues. In general, no one may perform surgical procedures on a minor without first obtaining the written consent of the parent or legal guardian, except in the case of an emergency when such procedure is necessary for the treatment or serious disease, injury or drug abuse, to save the patient’s life, or where the parent or legal guardian cannot be found after a reasonably diligent effort (A.R.S. § 36-2271). Obtaining consent is required for injections and recommended for examinations of patients’ bodies where there are special privacy concerns. (Such consents do not take the place of a nurse or other appropriate witness if pelvic or breast examinations are to be done for physically mature minors.) The consent of a parent or guardian is required for vaccinations given to minors (A.R.S. § 32-1974(M)).” Arizona Minor Healthcare Laws *Disclaimer: Laws are subject to change and may not reflect current statutes. This is not intended to serve as legal or medical advice. “The minor may consent if one of the following conditions apply: • The minor is emancipated, married, or homeless (A.R.S. § 44132); • The care relates to sexually transmitted diseases (A.R.S. § 44132.01); • The care relates to rape or sexual assault and the minor is 12 years of age or older (A.R.S. § 13-1413); • The care relates to alcoholism (A.R.S. § 36-2024); • The care relates to substance abuse and the minor is 12 years of age or older; (A.R.S. § 44-133.01) or • The care relates to HIV testing (A.R.S. § 36-663).” Case Study Until a few months ago, Jason, 16, did well in school and was active in student government. His parents notice that his grades have since deteriorated, he has started skipping school, he has changed his dress and friends, and has been avoiding his family. His mother made an appointment for a checkup and asked your staff to perform a urine drug screen without Jason’s knowledge. You see Jason alone and he denies using substances other than infrequent marijuana use. His physical exam is normal. From this history, appearance, and demeanor, you are worried about drug abuse. What should the pediatrician do? Case Study Legally: There is no statute regarding a minor’s consent to drug testing. The knowledge or consent of the minor is not required in Arizona. Ethically: What do you think? Case Study Lucy is a 15 year old female who presents to her pediatrician for a general check up. During the check up, the pediatrician notices that Lucy is nervous and seems to want to ask for something but does not want to ask in front of her patients. The pediatrician asks Lucy’s parents to step out, during which time Lucy admits that she is currently sexually active and she would like to start birth control. Even though the pediatrician suggests that Lucy shares this information with her parents, Lucy is absolutely against it. You know that Lucy will need to be screened for STIs and that her birth control would include a $30 copayment, both of which will likely show up as an Explanation of Benefits in her insurance bill that will go to her parents. What should the pediatrician do? Case Study Legally: Lucy can consent for testing and treatment of STIs. No statute specifically for family planning, but opinion issued by the State Attorney General in 1977 states that a minor may consent to family planning service. Ethically: What do you think? Questions?