For teenager, 'confidential' is conditional
HEALTH SENSE
By Judy Foreman, Globe Staff, 01/18/99
Adolescence is hard enough, but when it comes to health care, teenagers
are caught in a particularly delicate bind. They're old enough to face
the same serious issues as adults - contraception, abortion, depression,
alcohol or drug use - yet not old enough to have the same guarantees
of confidentiality when they seek help.
Granted, confidentiality is not absolute for adults, either. If an adult
poses a danger to himself or someone else, or is abusing or neglecting
a child or a vulnerable adult, the doctor can, and often legally must,
intervene.
But because adults can authorize their own care, and because they pay
for it or have insurance that does, they have substantially more rights
to confidentiality, at least in theory. Not so with teens.
In Wisconsin, teens can't get any medical care care - except for evaluation
of drug overdoses or in life-threatening emergencies - without prior
written consent from a parent or guardian.
In most other states, a parent or guardian must authorize non-emergency
care (not necessarily in writing), though teens can often be tested without
parents knowing, and sometimes treated, for sexually transmitted diseases,
including HIV infection, and for pregnancy diagnosis and contraception.
The degree of confidentiality a teenager has also depends on whether
he or she is legally "emancipated" or "mature," notes
Richard Bourne, associate general counsel for Children's Hospital in
Boston.
In Massachusetts, for instance, a judge can decide that a teenaged girl
is mature enough to make her own decision about abortion. In some cases,
a doctor or other health care provider, rather than a judge, can decide
that a teenager, male or female, is mature enough to consent to certain
types of care.
But for many teenagers caught between childhood and adulthood, confidentiality
can be elusive. Teens often "go to a doctor for advice because they
don't want to ask their parents about something or don't want to alarm
their parents," says Jeff Maranian, 17, an Arlington High School
senior and member of an ongoing teen council convened by Tufts Health
Plan to enlighten doctors on how teens want to be treated.
"Confidentiality is extremely important to teenagers," he adds.
He has no problem with doctors' telling parents a teen is suicidal. But
drug use? "No, that could be worked out between the doctor and patient."
Contraception? "I don't think a parent needs to know about that."
Indeed, with some issues like HIV, it may be "safer for the teen
if the parent doesn't know about the testing itself," says Nicole
Dray, a 16-year-old Lexington High School student who is also on the
Tufts council.
"If they feel their parent will flip out about their having the
test, they might not have it, which would be bad," she says. "Some
parents might think that if a teenager wanted the test, it means they
are having sex with lots of partners or are using drugs. It might just
mean they had sex once and want to be sure they're okay.
"On the other hand, if they have the test and it's positive, they
obviously will have to tell their parents at some point." Several
studies back up the notion that teens are more likely to confide in doctors
if they know their concerns will be kept confidential, says Dr. S. Jean
Emans, chief of the division of adolescent and young adult medicine at
Children's Hospital.
Ideally, pediatricians should raise the issue of confidentiality when
the child is 10 or 11, says Dr. Michael McKenzie, assistant medical director
for pediatrics at Tufts Health Plan.
"I do it in front of the parents. I say, `When you begin to see
me by yourself - and that decision is up to the teen - that what we talk
about is confidential." He adds that if the teen threatens harm
to himself or others, "that may be cause to talk to your parents
against your wishes."
And he forewarns: "If I hear something from you that I think your
parents need to know and help you with, I will find a way to broker this,
to help you talk to your parents about this."
But it gets sticky, especially in "family practice," where
everybody in the family has the same doctor. Privacy can also get compromised
in schools, where parents may have a right to see school records, including
those of a school counselor. And there's even less confidentiality for
teens who are delinquent, in jail or on court probation.
Basically, medical and psychiatric care for adolescents boils down to
a matter of "conditional confidentiality," says Emans.
Part of the problem is that kids are caught in an "economic trap,"
says clinical psychologist Gary Schoener, who specializes in ethical
and legal issues and runs the Walk-In Counseling Center in Minneapolis.
Like battered women whose husbands pay the bills, teens may see their
confidentiality shattered because parents either pay for their care or
see insurance records.
What may work best is for the doctor to figure out, with the teenager,
how to tell parents what's going on or persuade parents to back off enough
to give the teenager some privacy.
Sometimes, it helps to bring parents into the office, instead of just
coaching the teen on how to talk to parents. Sometimes, it means persuading
a teen to let parents know some things but not everything.
And in some cases, teens find it helpful to turn to the Internet with
questions they might be afraid to ask a doctor in person, says Dr. Steven
Adleman, medical director of substance abuse services at Harvard Vanguard
Medical Associates in Boston. He runs a website, www.drsteve.org, which,
he says, is increasingly being used by teens with questions about their
use of alcohol, drugs and tobacco.
"I feel safer asking someone who can't see me," wrote one high
school senior concerned about binge drinking. Another teen, an eighteen-year-old
high school dropout who uses drugs, wrote, "This site is great for
someone like me who is afraid to go to the doctor and afraid that my
parents will find out I use drugs."
But even with the best intentions, confidentiality can be jeopardized
in situations that no one could have foreseen, says Thomas Grisso, a
clinical psychologist and director of forensic training and research
at the University of Massachusetts Medical School.
That can happen, for instance, when a teenager has been in psychotherapy
for a while. Then the parents divorce, and a custody battle ensues. Sometimes,
the court appoints a guardian to protect the teen's interests. But the
attorney for one side may subpoena the teenager's therapist.
"Now you have the clinician stuck between his ethical obligation
to maintain confidentiality to the child...and the legal order," says
Grisso.
The bottom line is not that you shouldn't seek mental health or medical
care when you need it. You should. But do so with your eyes open.
"Be neither blindly trusting nor blindly cynical," advises
Dr. Harold Bursztajn, who co-directs the Program in Psychiatry and the
Law at the Massachusetts Mental Health Center, a Harvard teaching hospital.
"If the doctor raises the question about getting in touch with your
parents, go ahead and think of why or why not and talk about it," he
says. And if the answer is no, "say what you are afraid of, because
there is something there that needs to be addressed, and it may not be
in your mind."
Judy Foreman is a member of the Globe Staff. Her e-mail address is: foreman@globe.com.
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