The relationship between parents and pediatricians is unique. More than any other field of medicine, there is a level of trust that develops because of the consistent and ongoing interaction for several years. But as the child grows older and enters the adolescent years, the relationship shifts from catering to the desires of the parent to the needs of the child.
When a strong relationship is established, the transition of trust is usually easy, and parents are very comfortable and welcoming of an independent relationship between the physician and the child. But there are many issues that come up in adolescence that may be very difficult for a child to discuss with the parent despite having a good relationship, putting the physician directly in the middle.
The issue of minor consent is complex, and because it differs from state to state, it becomes even more complex. Of course, the best approach is to have a conversation with the parent to determine their views on various issues and ask for consent to address them should their child present to you for treatment, but new patients present, and time to establish a relationship is not always possible. The American Academy of Pediatrics statement on treatment of adolescents requires that every attempt is made to encourage inclusion of the parent in any decision making.
Understanding the laws that govern the state in which you practice is imperative. The state policies and laws can be found at www.Guttmacher.org . Although there has not been a physician held liable for nonnegligent care given to a minor who gave consent, it is important for parents to understand what their child can consent to or against. It also is important for the physician to be explicitly clear as to what their limitations are by law.
A minor status is defined by age under 18 years of age. An emancipated minor is someone who attained legal adulthood because of marriage, military service, or living separately from parents and managing one’s financial affairs (Understanding Legal Aspects of Care, in “Adolescent Health Care: A Practical Guide,” 5th ed [Philadelphia Lippincott Williams & Wilkins, 2008]). These laws are very clear and do not usually cause much confusion. Where the situation becomes very grey is in the case of the mature minor. This category is recognized in some states as an exception to the rules requiring parental consent for medical care ( Int. J. Gynaecol. Obstet. 1998;63:295-300 ). The mature minor is defined as being at least 14 years old, having the ability to understand risk and benefits, and having the ability to provide informed consent. But this requires a subjective assessment of the adolescent, which could be argued by the parent.
Minors can consent to contraceptive services in most states. In 1977, the Supreme Court ruled that the right to privacy protects a minor’s access to nonprescriptive contraception, and although prescribed contraception is not included, it is generally considered to be included ( Med. Clin. North Am, 1990; 74:1097-112 ). It is important to note that a pharmacist under the Pharmacist Conscience Clause, in some states, can refuse to fill the prescription without parental consent at their discretion ( Arch. Pediatr. Adolesc. Med. 2003;157:361-5 ). Although this not a common issue, it may present a larger issue if the patient requested confidentiality.
Diagnosis and treatment of sexually transmitted disease also can be done with the consent of a minor, but the age of the patient, usually greater than 14 years, is required in most states. A careful assessment must be done for abuse regardless of whether the minor admitted to consensual sex or not. The laws regarding statutory rape are clearly defined state to state and may present a larger problem if disputed by the parent.
Elective abortion is always a topic of debate. States require at least one parent to consent when a minor is seeking an abortion, but a minor also can seek a judicial bypass, which is a request from a minor to not have parental consent for an abortion if they believe that notification will bring harm to the minor. Conversely, an adolescent also can refuse to consent to an abortion that the parent requests.
Immunizations also can be given with the consent of the minor, but extra precaution should be given to documentation of clear explanation of risk and benefits. Despite there being no federal law requiring parental consent, some states do require it, and it is prudent to obtain it.
Parents don’t often realize the limitations of their ability to prevent or demand treatment. So although the abortion itself falls outside the scope of care of a pediatrician, educating parents on the laws can help them navigate the situation better. Parents also may request drug, sexually transmitted infection, or pregnancy testing without the knowledge of the minor. Whether it is done is left to the discretion of the physician but the AAP advises that this only be done as a rare exception ( Pediatrics 2007;119:627-30 ).
Now a larger consideration for physicians is financial liability. Parents are not obligated to pay for treatment and procedures for which they did not consent. The financial responsibility falls on the minor who requested it. Obviously, this could be costly for the facility, and therefore a decision has to be made to either disrupt continuity of care and refer to an outside facility or absorb the cost. This can be a challenging decision. Disclosing to the minor that payment sent through the insurance might unintentionally breach the confidentiality of the treatment is also an important consideration if the minor’s desire is to keep the parent uninformed.
The issue of consent to treatment when it comes to minors is multifaceted. Maintaining the trust of the parent and gaining the trust of the adolescent is tricky when the lines of communication between them are limited. Establishing early a relationship of trust with the parent to advise and treat the child appropriately in the event he or she does present with complex issues will settle many of the issues. More importantly, as pediatricians our goal is to establish a relationship with the adolescent so that he or she knows where to go to get good sound advice and treatment to ensure good health and prevent avoidable consequences.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at pdnews@frontlinemedcom.com. Scan this QR code to view similar columns or go to pediatricnews.com.
