- Sara Lan
Confidentiality protection is an essential component of a patient-physician relationship. Only in a setting of trust can patients feel comfortable sharing personal feelings and sensitive information regarding their health with their health care providers. Having access to confidential health services is especially important when the patients are adolescents. This is particularly because the medical care needs of adolescents can often conflict with the opinions and values of their family members. Therefore, adolescents are less likely to seek medical treatment if they fear that the information they share with their medical care providers might be disclosed to their families. On the other hand, this fear may also cause adolescents to withhold certain information from medical professionals which can create problems in providing accurate diagnoses. Thus, medical care providers should do everything they can to respect adolescent patients’ confidentiality unless the patients are at significant risk of harming themselves or others.
Confidentiality is linked in to several bioethical principles, including the principle of respect for patient autonomy, the principle of beneficence, and the principle of nonmaleficence.
Within bioethics, the principle of respect for patient autonomy is usually associated with allowing informed and competent patients to make their own choices regarding their medical treatments (15). Meanwhile, confidentiality is respecting a patient’s right to control the information relating to his or her own health. While these concepts generally refer to adult patients, adolescents of Bill’s age are presumed competent to make medical choices for themselves. Unless the law requires otherwise, a competent minor can consent to medical care without involving the patient’s parents. In this particular case, Bill has good reasons for his reluctance to disclose the information that he has shared with the medical team to his parents. Bill mentions that his parents have explicitly expressed their views against same sex marriages and negative opinions about gays and lesbians. Therefore, in respecting Bill’s confidentiality and keeping information about Bill’s sexual orientation a secret, the medical team is acting beneficently. At the same time, disclosing the information to Bill’s parents presents the potential for harm. For instance, Bill may face rejection from his parents as a result and this may cause his depression to worsen. Thus, maintaining confidentiality can also be seen as acting in the principle of nonmaleficence.
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Concerns with regards to Bill’s competency may arise due to his past suicide attempt. In cases involving minors who do not have the capacity to make their own health care decisions, parents are generally the default surrogate-decision makers (94). Consequently, some people may argue that Bill’s medical decisions should be determined by his parents. Furthermore, by invoking the best interest standard, they might add that knowing all relevant information is necessary in determining what treatments are most beneficial for Bill. This can be justified if Bill is deemed incapable of making his own medical decisions then his parents may need to know about the causes of his depression in order to decide what specific types of medical treatments he needs. However, based on the sliding scale model of competency, I argue that Bill does in fact have the competency required to make his own health care choices. According to the sliding scale of competency, medical treatments that are highly beneficial with relatively small risks require a low level of competency to provide informed consent (90). Bill’s treatment plan fits into this category quite well. Furthermore, due to the highly therapeutic nature of these types of treatments, a presumption of competency holds when a patient agrees to treatment because the patient is making a rational choice (90). Although Bill’s competence may be questioned again when medical treatments involving higher risks are involved, he is still capable of making his own decisions about the treatment plan that is offered to him at the moment.
While it is important to respect a patient’s autonomy and confidentiality, the medical team should still encourage conversation between adolescents and their parents. When an illness strikes a member in the family, it not only affects the patient, but also the patient’s family as a whole. For that reason, in “Bioethics for Clinicians: Involving Children in Medical Decisions”, the writers proposed a family-centred approach which takes into consideration the burdens and the benefits for all family members, as well as their responsibilities toward each other (93). Since family members can provide much-needed support during the patient’s illness, medical care providers should always encourage communication between a minor and his or her parents. If Bill agrees to it, the medical team can speak to his parents about his treatment plan in more general terms. For instance, adolescence can generally be a difficult time for many people. Being the transition stage between childhood and adulthood, there are unique challenges and struggles that exist in this stage of life such as developing a personal identity. Therefore, it is not uncommon for adolescents to seek therapy and counselling for one reason or another. For the same reasons, schools also have counsellors to guide and help adolescents deal with these issues in life. By framing Bill’s treatment plan in this way, the medical team is able to provide a way for Bill to communicate and obtain support from his parents while he undergoes treatments without disclosing Bill’s secret.
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It may be objected that withholding information from Bill’s parents is the same as lying. This objection is understandable since certain information does in fact have to be withheld when discussing Bill’s treatment plan with his parents as a means to protect Bill’s confidentiality. Nevertheless, the motivations behind lying and moral acts of withholding information are fundamentally different. For this reason, I argue that lying and moral acts of omission should not be viewed as equal. In “When Self-Determination Runs Amok”, author Daniel Callahan also speaks of the moral differences associated with “stopping life-sustaining treatments” with informed consent and “active forms of killing, such as a lethal injection” (345). Clearly, lying and active forms of killing are motivated by maleficence. Other the other hand, stopping life-sustaining treatments with informed consent and moral acts of withholding information are based on medical professional duties. Ultimately, should the medical team lie to protect Bill’s confidentiality? The answer is no. Under no circumstances should the medical care providers lie. After all, no one would be willing place their health and well-being in the hands of medical professionals who are capable of dishonesty. Meanwhile, moral acts of omission are justifiable when disclosing full informationwill very likely cause predictable harm. Generally, people find the latter to be acceptable.
If Bill’s depression does not improve with treatment and he is at significant risk of harming himself again, confidentiality may be justifiably breached. The medical should convey their intention to breach confidentiality to Bill before notifying his parents of his risk of harm to himself. However, it should be noted that it is not appropriate for the medical team to disclose information about Bill’s orientation if he does not wish for that information to be disclosed. It may take years before Bill feels comfortable sharing this information with his parents. Ultimately it is up to Bill to decide when he is ready. For the time being, the medical team’s role is to encourage a healthy support network between Bill and his family as well as to ensure that Bill has a confidential environment for his health care needs.
Gedge, Elisabeth (Boetzkes), and Wilfrid J. Waluchow. Eds. Readings in Health Care Ethics. 2nd ed. Peterborough: Broadview, 2012. Print.
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