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Presentation at a
training program ‘Applying the Principles of Ethics to Clinical Practice:’
held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan Kasule Sr. MB
ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King
Fahad Medical City.
OBJECTIVES
At the completion of this topic students would have
explored some of the issues related to sexual history, confidentiality and
ethical concerns.
GILLICK COMPETENCE
·
The UK Health Department issued a policy
that doctors could prescribe contraceptives for girls under 16 without the
parents' knowledge or consent.
·
A mother Victoria Gillick took the
government to court claiming that the policy would encourage sex with a minor
and was treatment without parental consent.
·
The House of Lords (the highest court in
England) ruled that the child could consent to contraceptives if she understood
the medical treatment involved (test of Gillick competence) and that the
parents could not veto her decision.
·
A child who is Gillick competent can
prevent parents viewing her medical records without her consent.
·
An emancipated minor is one who is
married or is in the military.
FRASER CRITERIA ON CONTRACEPTION FOR MINORS
·
the young person will understand the
professional's advice;
·
the young person cannot be persuaded to
inform their parents;
·
the young person is likely to begin, or
to continue having, sexual intercourse with or without contraceptive treatment;
·
unless the young person receives
contraceptive treatment, their physical or mental health, or both, are likely
to suffer;
·
the young person's best interests require
them to receive contraceptive advice or treatment with or without parental
consent.
CASE #1
A 14-year old school girl with painful and irregular
menstrual periods saw a school physician who prescribed oral contraceptives to
regularize the period. She refused saying that if her parents found out they
would suspect that she was engaged in illicit sexual relations. She only agreed
to take the treatment when the physician promised that he would not disclose
the information to school authorities or parents without the patient's permission.
CASE #2
A 15-year old girl asked a private gynecologist for an
abortion after missing her period following a rape by a person close to her
family. She asked the gynecologist to keep it a secret from the parents because
if they knew they could kill her or kill the rapist.
CASE #3
A 13-year old teenager with a foul smelling vaginal
discharge went for treatment at the school clinic and asked the nurses not to
disclose the condition to her parents because they would suspect her of having
sexually transmitted infections.
CASE #4
Angela Milton, a 20 year-old female, presents with a
three-week history of vaginal discharge. Angela has taken the very positive
step of seeing her GP about genitourinary symptoms. A full sexual history is
essential, and Angela is most likely to give full and honest responses to
questions if she feels that the doctor's attitude is supportive, confidential
and non-judgmental. Failure to demonstrate these attitudes will lead to
withholding of potentially important information.
CASE #5
A 13-year old girl had been married to an older man
against her will. She missed her period 5 weeks after marriage and suffered a
miscarriage due to physical abuse by her husband. When taken to the doctor she
refused to admit the miscarriage and maintained it was a heavy and painful
menstruation. She was afraid that her cruel husband would suspect she had
deliberately aborted his baby. As a result the doctor misdiagnosed the case and
she suffered severe post abortal infection and hemorrhage because the uterus
had retained products that were not removed.
Issues to Discuss
·
Confidentiality - the
importance of confidentiality to adolescent patients, the practicalities of
offering and maintaining confidentiality, and the consequences of failure to do
so.
·
Doctor-patient relationship - the
ethics of the patient-doctor relationship, boundaries and strategies for
susceptible situations.
Loughrey J. Medical information,
confidentiality and a child's right to privacy.
Leg Stud (Soc Leg Scholars). 2003
Sep;23(3):510-35.
·
Following the Gillick case in 1986, it
was recognised that mature minors were owed a duty of confidentiality in
respect of their medical information.
·
Subsequent cases confirmed that the duty
was also owed to non-competent children, including infants, but without
explaining the basis for finding the existence of such a duty and its scope.
·
It is particularly unclear when and upon
what legal basis a doctor could disclose information to parents when their
child wished to keep it confidential.
·
This paper will examine the law of
confidentiality as it applies to children, identifying issues which are
problematic. Developments in the law of personal confidences which have taken
place as a result of the Human Rights Act 1998, and the recognition of Article
8 rights as part of the law, will be reviewed and analysed from the perspective
of the duty of confidence owed to children in respect of their medical
information.
·
Finally, the paper will offer an
explanation of a basis for disclosure to parents which minimises violations of
a minor's autonomy.
Cornock M. Confidentiality: the legal
issues. Nurs Child Young People. 2011 Sep;23(7):18-9.
·
In children's nursing confidentiality is
a principle that combines legal obligations and ethical standards. This article
outlines how this principle applies to nurses in the course of their
professional duties with children, young people and their parents and carers.
·
There is also a discussion about 'Gillick
competence' and exceptions where a nurse is obligated to breach
confidentiality, such as in cases of suspected child abuse.
Teoludzka A, Bartholomew TP. Queensland
general practitioners' applications of the "mature minor" principle:
the role of patient age and gender. J Law Med. 2010
Dec;18(2):390-401.
·
Most Australian jurisdictions do not have
legislation that stipulates an age by which a minor can make their own medical
treatment decisions. Instead, they rely on Gillick v West Norfolk and Wisbech
Area Health Authority [1986] AC 112, an English common law decision that
recommends individual assessments of "maturity".
·
This study explores how medical
practitioners in the State of Queensland understand and apply this legal
authority when faced with a young person wishing to make a contentious medical
treatment decision.
·
Almost 200 doctors made decisions about a
hypothetical patient's competence and confidentiality, and detailed their
reasoning in an open-ended format.
·
The data indicate that the vagaries of
existing legal criteria allow for a range of philosophical perspectives and
idiosyncratic heuristics to play a role in assessment practices, and that
particular combinations of patient age and gender made these cognitive
shortcuts more likely to occur. A notable proportion of such processes are not
consistent with legal guidelines, and this has implications for general
practitioners' vulnerability to litigation as well as young patients' treatment
trajectories.
Cave E Adolescent consent and
confidentiality in the U.K. Eur J Health Law. 2009
Dec;16(4):309-31.
·
In R (Axon) v Secretary of State for
Health the Gillick competence test was confirmed. Commitment to childhood
autonomy and privacy rights caused renewed academic criticism of the 'refusal'
cases.
·
This paper considers the form any changes
to the law may take, and the potential consequences for the rights of parents
and young people.
·
Silber J.'s contention that parental
Article 8 rights cease when the child makes a competent decision is potentially
problematic if applied to refusal cases, especially in the context of the
distinction between competence to consent to treatment and to the disclosure of
information.
Unsworth-Webb J. Potential termination of
pregnancy in a non-consenting minor. Nurs Ethics. 2006
Jul;13(4):428-37.
·
The pregnancy of a 12-year-old girl
provides the basis for a consideration of approaches to a dilemma brought about
by conflicting expectations.
·
Here, medical opinion is to reject action
implied by the lack of Gillick competence and by a 'parental responsibility'
claim adopted by the girl's mother.
·
Construction of the dilemma and the
subsequent process, which sought resolution, illustrates that the Gillick
ruling, and other guidelines intended to be helpful, can prove to be less so.