Abstract
Children and adolescents often have concerns about confidentiality when divulging personal information. This suspicion often force them to desist from seeking necessary medical care and counseling, subsequently creating barriers to open communication between patient and physician. As such protection of confidentiality is needed to appropriately address issues such as depression, suicide, substance abuse, domestic violence, unintended pregnancy and sexual orientation. This way, the young people will certainly have the opportunity to communicate and avail relevant medical and counseling services they require in various arising circumstances.
Introduction
Confidentiality reflects to the importance of keeping information the patient deems important to him and, if, without his consent and authority, divulged to a third party would be damaging to his self confidence and also his trust with the second party, leading to a communication barrier between him and the important services and physiological needs he requires to address a problem related to the confidential information.
This aspect of confidentiality is a derivate of children and teens lack of capacity to facilitate for their needs. This is well described by the fact that, children and adolescents are dependants since they lack abilities to address their needs, live under the guardianship of parents and are obliged to remain so until deemed able and proves able to provide for them-selves.
If confidentiality is not prioritized in arising cases which minors speak out about to a physician, then the subsequent situation is that the minor lacks autonomy, self confidence and a moral authority to address his/her problems.
Consent is a derivate of confidentiality and the principal that guides both the physician and the patients in the clinical process of addressing the patient’s problem. Both patient and doctor should have an informed consent. For the doctor he should look at consent on two dimensions, one the medical aspect of the subsequent medical advice and treatment and the information the patient gave about his condition. As such, he should inform the patients of the effects of the medications risks and adverse effects.
For both, informed consent requires that the physician inform the patient about all the concepts and aspects of the treatment and the therapy. This makes the physician oblige and abide to a set code of ethics by the society and the legal framework of the medical policies. This way, treatment and therapy as well as consulting on behalf of the patient through referral or informing the parents of the impending conditions becomes an integral part of the physician.
According to Schipske (2006) “The person who will actually perform the medical procedure should obtain the consent. In every state, common law requires health care providers to obtain informed consent before performing medical procedures that carry a higher than usual risk. Informed consent requires a provider to disclose all information that is material to the patient’s decision about whether to agree to a medical procedure”. Without such faculties being looked into as basic procedures, the autonomy of the patient is at risk.
Minors and their autonomy
Regardless of their minimal capacity to facilitate for themselves, children and adolescents have the decision-making capacity and regardless of their age, should be involved in their health care decisions. This way, they learn responsibility at these early stages of life and subsequently become responsible of their problems leading to their ability to resolve and meet emerging health challenges in their lives. Dickey, Kiefner and Beildler (2007) argue that “When clinical care proceeds without attention to a child’s emotional and developmental potential, the needs of a young person to be socialized to take care of his or her health care from an early age are not met. This is ethically irresponsible. Developing competence for informed consent decisions is associated with cognitive capacity”.
The role of parents in the healthcare of their children is important based on the parent responsibility perspective. However, lack of participation by the child or the teenage child is not a responsible decision. This is due to the fact that, involving them will result to them developing them-selves to become aware of their healthcare needs and how they shall address their illnesses.
The need to recognize adolescents as autonomous members of the society is very important. This ethical consideration leads to these young people becoming citizens with autonomy and confidence in the society. As such recognizing this aspect of the children is an ethical principle.
Arising area’s of concern
Major concerns in the health of the adolescents are mainly in the reproductive health. Cases of sexually transmitted infections and pregnancies as well as teenage sex are becoming increasingly bothersome in the latent modern society. Parents are faced by multi-faceted scenarios of underage pregnancies and HIV/AIDS cases. Children are more than involved in sex than estimated.
Secondly, substance abuse and criminal activities have become issues within the society. Parents and counselors have the obligation to advice, arrest cases and make proper treatment referrals. Here, therapy and clinical recommendations require the consent of the young person as well as that of the involved parties. As such “Fulfilling the rights of adolescents requires a balance between providing them with protection and enabling them to assume adult roles and responsibilities. Consent and confidentiality issues are a constraint in access to health services for adolescents” (WHO, 2007). This means there is an urgent need to identify areas which are of concern and how to revise existing legislations as well as services and ethical requirements. According to WHO (2007) “adolescents comprise 22-25% of the population; The problems relating to sexuality and reproductive health and the increasing trend of HIV/AIDS in adolescents and young people, the poor capacity of health care providers and variation in policy has brought the concerns relating to consent and confidentiality to the forefront”.
Advocacy for consent and confidentiality
The need for consent and confidentiality is mainly aimed at the health provision sector.
The need for guidelines on confidentiality and consent issues is of importance health for service providers and program managers.
These include (see WHO, 2007)
An overview laws, polices and practices relating to consent and confidentiality for adolescents.
Identifying strengths, weaknesses and gaps within policies and practice, from the perspective of the providers and users of health services
Identify priorities for action, at national, organizational and facility levels, to improve policies and practices regarding consent and confidentiality for adolescents.
To develop draft guidelines for service providers and mid-level managers to better respond to the consent and confidentiality needs of adolescents.
To develop plans for using the guidelines developed by selected countries participating in the consultation.
Health care provisions and the arising issues of consent and confidentiality
Dickey, Kiefner and Beildler (2007) point out that, adolescent is a tender stage of growth and development. It is the most integral stage of development. According to WHO (2007), “Adolescence is a period of rapid physical and psychosocial development: no longer small children, and not yet adults. There are changing roles and expectations, which pose challenges for the adolescents themselves and for the societies in which they live. Adolescents have many common characteristics, but they are also different. (age, sex, marital status, parental support, etc.). All adolescents are vulnerable, but some are more vulnerable than others”
As such, the need to address the arising issues affecting the health of these young people is a concern of the society as well as parents and the health providers as well as the government.
The expectations of the society about the young people are varied based on gender, background, marital status and also social status. Adolescents maybe be able to achieve various distinctive things in their lives, but they lack capacity to offer or make informed consent about medical provisions.
According to Schipske (2006, WHO, 2007) “adolescents are capable of understanding information, appreciating risks, and making informed decisions. However, all adolescents do not develop at the same pace: age is therefore only one factor that needs to be taken into consideration when assessing an adolescent. Depending upon their stage of development, adolescents need: information and skills; health services and counseling; and a safe and supportive environment. It is vital to ensure that young people have access to prevention and treatment, and testing is an important entry point in this regard.
This means respecting choice and rationale of the child is very important in modeling successful and responsible adults in the child while at the same time establishing a proper mechanism of treating the adolescent. This maybe mistaken for endorsement of their recommendations in terms of referral and prescribed medical provisions and therapeutic recommendations, but this merely translates as identifying the physiological needs as well as the rights of this young adult; Besides, listening to their opinions means showing understanding and respect to their perceptions. The subsequent results are that, this decision provides children and adolescents the possibility of understanding the reasons for a different decision being taken, and will allow them to become active partners, with appropriate skills to participate in program, conceptualization, design, implementation, coordination, monitoring and review (WHO, 15).
Levels of adolescent/children needs
Society and doctors labels adolescents and children as vulnerable and most needy members of the society. The social care sector describes the needs of children and young people according to a levels approach: (see Child and Adolescent Mental Health
2006)
• ‘A Child in need is a child or young person whose development needs cannot be met by their family or careers solely through the support of basic services’
• Level Four Need – Children with the most complex needs and high levels of vulnerability
• Level Three Need – Vulnerable children who require an immediate, short term response
• Level Two Need – Vulnerable children who require further assessment of their needs
• Level One Need – Potentially vulnerable children, who require access to services to prevent the development of problems
• Base Level – All children
Understanding consent and confidentiality
Based on the United Nations principles on child rights, understanding consent and confidentiality is expounded and easily understood by practitioners (see UN Convention on the Rights of the Child, the Children’s Act, the Health and Safety Act, the Data Protection Act).
To understand the context of consent and confidentiality means to have a clear understanding that confidentiality means a physician being concise about his professional position when dealing with cases as well as being aware of the tension this can cause. It also implies having an understanding of what re the legal implications arising incase of breach of confidentiality as well as any other arising legal or medical implication. It means having knowledge of the following guidelines about resolves and healthcare provisions. They are; Who can give it? at what age/stage of maturity it can be given? The specific legal issue relating to “consent” for young people
Best practice when handling adolescent and children in need
Various contexts of rational and professional mechanisms as well as ethical modalities of addressing children and adolescent problems have been in use. However, professional approach towards the issue of consent and confidentiality needs more than that.
It is advisable not to discuss a case on the open, especially in places where you are likely to be overheard. The adolescent assumes you will speak in public and obviously shame or even tell away the problem to parties he didn’t wish to come across the confidential case.
It is advised that the history of the patient should not become hypothetical in your approach. It only amounts to the teenager assuming you are about to overt her personal profile the clinical problem she might be facing. This obviously reduces her trust in you and hence, results to breakage of communication and confidentiality.
All questions in spite of the setting should be addressed to the adolescent and not the parent. This gives the adolescent autonomy and confidence in explaining her situation more concisely.
According to Adolescent Health Working Group, (2002) “a young person is more likely to disclose sensitive information to a health care provider if the youth is provided with confidential services, and has time alone with the provider to discuss his/her issues, and that even when the chief complaint is acne or an earache, there may be underlying issues on the part of the adolescent (such as the need for a pregnancy test or contraception), which will only surface when provided confidential services.”
Legislation on teen confidential issues
Based on recommended standard measures, the best practices to keep consent and confidentiality are as below (see Adolescent Health Working Group, 2002)
In the cases of pregnancy the health care provider is not permitted to inform a parent or legal guardian. (Cal. Health& Safety Code §§ 123110(a) and 123115(a))
In the case of contraception, the health care provider is not permitted to inform a parent or legal guardian. (Cal. Health& Safety Code §§ 123110(a) and 123115(a))
On abortion, the health care provider is not permitted to inform a parent or legal guardian. (Cal. Health & Safety Code §§ 123110(a) and 123115(a))
On the case of emergency medical services, the health care provider shall inform the Minor’s parent or guardian.
In the event of sexual assault or rape, the health care provider must attempt to contact the minor’s parent/guardian and must note the day and time of the attempted contact and whether it was successful. This provision does not apply if the treating professional reasonably believes that the parent/guardian committed the rape or assault.
(Note: This provision does not apply if the minor is over 12 and treated for rape)
Abuse, skeletal abuse/problem, neither the physician-patient privilege nor the psychotherapist-patient privilege applies to information reported pursuant to this law in any court proceeding.
In the event of sexually transmitted diseases, health care provider is not permitted to inform a parent or legal guardian without minor’s consent. The provider can only share the minor’s medical records with the signed consent of the minor. (Cal. Health & Safety Code §§ 123110(a) and 123115(a)) (See Adolescent Health Working Group, 2002)
Sources
Adolescent health working group, (2002); Understanding confidentiality and minor consent in California pg 4-27
Child and Adolescent Mental Health training & development
Project (2007): Capabilities needed for effective working with children and adolescents
www.camhs.org
WHO (25-27 July 2006) Consent and Confidentiality: Increasing Adolescents’ Access to Health Services for HIV and Sexual and Reproductive Health, Report of the Regional Consultation New Delhi, India, pg 7-53
S. Dickey, J Kiefner, M. Beidler (2007), Consent and Confidentiality Issues among School-Age Children and Adolescents The Journal of School Nursing Article: pp. 179–186
