COMMENTARY

Physicians Are Talking About: A Teen's Right to Privacy

Nancy R. Terry

Disclosures

December 30, 2009

A pathology technician working in the same hospital as her family physician views her daughter's medical record under questionable circumstances. Alarmed to learn that her teenage daughter has had a Pap smear, the mother calls the physician to ask if her daughter is sexually active. Faced with responsibilities to both mother and daughter, what should the physician do?

The question -- posed to contributors to Medscape's Physician Connect (MPC), a physician-only discussion board -- sparks an animated debate.

The majority of MPC contributors say that the physician's first duty is to his or her patient. "The daughter has a right to privacy," says a pediatrician, "and the doc has no medically urgent need to breech that privacy." An obstetrician/gynecologist agrees, "Teens have a right to sexual privacy. We don't give Mom the results unless the daughter allows us to -- in writing."

A family medicine physician takes a different view. "The sexually active teenager is someone at particular risk for HPV, STDs, HIV, pregnancy, and sexual assault. Elevating the teenager's right to privacy over the parents' right to parent their child may be politically correct, but it's not doing anything to assist the parents in caring for, teaching, raising, or protecting their child with respect to the healthcare risks involved."

"As I understand it, in my state, the law does not say that a physician MUST protect the child's privacy," says an obstetrician/gynecologist. "The physician does not break the law if he or she discloses anything to a child's parents, regardless of the subject matter. However, the law does say that the physician can choose to protect the child's privacy and is protected if he or she chooses to do so. To me this is a big distinction. I see it as a judgment call on the physician's part."

An adolescent medicine physician comments that most states allow confidential contraceptive and sexual health services for teens, but physicians should be aware of their state's laws affecting minors. Typically, a patient of 17 years would be considered an adult in issues of confidentiality. She adds that the Guttmacher Institute provides an excellent overview of state laws (http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf). "I would tell the mother that she had no right to look at the results nor suspect any wrong-doing by her daughter," says a family medicine physician, "and I would call the daughter to tell her that her mother saw the results." An MPC contributor agrees that it is a good idea to notify the daughter. "It's best that she's not be surprised by her mother," opines an MPC contributor. "Mom might do something immature like say to her daughter, 'Dr. X told me why you needed a Pap smear. I'm going to give you a chance to tell me yourself.'"

Several physicians suggest deflecting the questions of the mother. "If you had to reply to Mom," says a pediatrician. "I'd say something like your daughter and I discussed her health, we felt doing a routine screening was appropriate."

Other physicians comment that the physician is in a position to encourage constructive discussion. "It would be better for both if you called them into the office and reiterated your role as the daughter's physician," says a family medicine physician. Another family physician comments, "Bridging the gap between them can be challenging," but says that "it can be accomplished with empathy, straightforward information, and support." He adds, "Once teens see that their doctor and their parents have been where they are, they are usually much more likely to involve their parents in future situations."

Yet, a pediatrician thinks the physician has no role as mediator. "Part of being sexually active is being mature enough to deal with the consequences. Whether this girl wants to deal with it by coming clean or by saying 'Dr. X said everybody should have a Pap at my age' is her own prerogative. But she needs to deal with it, not you."

Several physicians emphasize that volatile situations can be avoided by establishing the ground rules of confidentiality at the outset of care. "I explain to families that I will protect the child's privacy unless I feel that the child's life, health, or well being is in danger," says one pediatrician. "This seems to reassure most mothers that they will not be kept out of the loop for serious problems." The pediatrician comments that she keeps conditions for disclosure deliberately vague. "I would always insist that the parents of a sexually active 12-year-old be informed, but perhaps not for a 17-year-old who was acting responsibly. I always inform the teen when I feel it is necessary to talk with an adult, and offer to help her do this."

What sets this case apart is the mother's access to her daughter's medical records. "This is a sticky wicket," says an adolescent medicine physician. "Depending on what state you are practicing in, it could be illegal to discuss information with the mother. The mother has violated HIPPA, and in many systems can and should be punished." A pathologist comments that the mother, a pathology technician, could have seen her daughter's test results accidentally in the course of her duties. A surgeon counters that the mother is still culpable. "The mother was inappropriate in looking at her daughter's test," says the surgeon. "She was far more egregious in asking the physician for information."

"Mom violated HIPPA. Period," says a psychiatrist. "The doctor needs to tell the teen that privacy was violated and report it to appropriate authorities. And then fire the mother from the lab!" An orthopaedic surgeon takes issue with initiating disciplinary action. "That's perhaps the letter of the law but it is not morally right and will create more problems for Mom and for her daughter, the patient. Mom ought to be reminded that there are people out there who could fire her for such actions."

"The bottom line is do the right thing for the patient," says a nephrologist. "Tell the mother to wake up and begin some open conversations with the daughter, and not to do this again. Simple."

The full thread of this discussion is available at http://boards.medscape.com/forums/.29f699a8

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