She’s 15. She’s pregnant. And she arrives in a GP’s surgery, boyfriend in tow, asking for an abortion – ASAP. She and her boyfriend have talked it over at length and decided they are too young to have a baby. She asks the doctor not to tell her parents because they are religious and would never agree to the procedure. What should the doctor do?
Doctors themselves disagree. Seventy-nine per cent of GPs responding to a recent survey said they would respect the girl’s confidentiality and not talk to her parents without her permission.
Most – 82 per cent of women doctors and 75 per cent of male doctors – also regarded her as competent to make her own decision about having an abortion.
They were not so sure about their own competence. More than 70 per cent of the 300 doctors who answered the survey felt ill-informed about the legal issues underlying such cases, and 26 per cent felt that they had too much responsibility for serious decisions about underage patients.
Some parents, such as Mary Helen Woods, of the Australian Family Association, would agree with them on the latter point. She argues that doctors should inform guardians of serious physical or emotional problems in a young person. Many parents (and some doctors) would be surprised to learn, though, that the law says parents do not necessarily have a right to know.
Raising awareness of this issue was one of the reasons Terry Bartholomew, a lecturer in psychology at Deakin University, conducted the study, Young People and Informed Consent. The project was run in conjunction with the Centre for Adolescent Health and was funded by the Commonwealth Department of Health and Family Services. It surveyed 1000 GPs, of whom 300 responded.
Bartholomew asked doctors about four typical scenarios (including the pregnant teenager) in which teenagers asked for confidentiality or the right to make their own decisions regarding treatment:
The parents of “Adam”, 17, take him to the doctor when they discover he has been using heroin on and off for six months. They want him to see a psychiatrist; he rejects that idea and asks for some pills to ease his anxiety. “Liz”, 14, goes to her family doctor looking for birth control. Sixteen-year-old “Josie” presents with tonsillitis but is found to be suffering weight loss and an eating disorder.
Bartholomew says such situations are legally, medically and ethically complex. “Doctors are highly accountable, highly exposed and highly vulnerable,” he says. “It’s hard for them to err on the side of caution, because what’s the side of caution? They wonder, ‘Can the young person take me to court?’ ‘Will there be trouble from the family if they find out?’ ”
There were big differences in doctors’ responses, Bartholomew says: “Seven out of 10 doctors found Adam competent to make that decision. Three out of 10 didn’t. That’s an amazing discrepancy. These are significant levels of difference. Imagine if you went to doctors suspecting a broken leg, and seven out of 10 said ‘Absolutely!’ and the other three said ‘No way!’ ”
Doctors took the same factor and used it differently to come to opposite conclusions. In the Josie scenario, the girl admits her eating and exercising patterns have become problematic, but promises to stop dieting. “Her acknowledgement that there was an issue was interpreted in different ways,” Bartholomew says.
“The first was to decide that ‘Because she’s insightful about her problem, therefore she is competent’. The second was to say, ‘She’s pretending to have insight in order to manipulate my perceptions of her. That’s a classic tactic of someone with an eating disorder. She is not competent and needs help’.”
Other doctors argued that the very fact that Josie had symptoms of an eating discorder meant that she was “fundamentally pathological” and so could not possibly be competent to make decisions about her own care.
Doctors who arrived at the same conclusion often did so via different routes. Some decided confidentiality and competence simply on the basis of the patient’s age; others, according to whether they had a relationship with the young person’s family.
The law says parents do not have an automatic right to be informed. It is up to the doctor to decide whether the teenager is a “mature minor” capable of understanding the consequences of his or her choices.
The principle was established in 1985 in a British case involving Victoria Gillick, a Catholic mother of 10, who was seeking just the opposite. She took a doctor to court for having provided her 14-year-old daughter with a prescription for the pill. She lost the case in 1985 when the House of Lords ruled against her.
The “mature minor” principle was affirmed in Australia in 1992, when the High Court agreed with the Lords that “parental power to consent to medical treatment on behalf of a child diminishes gradually as the child’s capacities and maturities grow, and this rate of development depends on the individual child”.
The High Court said parental rights derived from parental duty and existed only as long as they were needed to protect the child: “The common law has never treated such rights as sovereign or beyond review and control.”
Mary Helen Woods is concerned that a single professional’s assessment of a teenager is all that is needed to determine their maturity. “GPs are often very overworked. Many of them are great people and they do a fantastic job, but you do hear stories of people in and out in five minutes, and there are GPs who are not particularly vocationally orientated in their outlook. These people, who may not have the best interests of the patient at heart, should not be allowed to make these decisions.”
Woods believes it would be dereliction of duty for a doctor not to inform parents of a condition that has the potential to be fatal and says any teenager suffering anorexia or taking drugs “could very well not be competent at all”. She goes so far as to argue that a responsible GP who feels uncomfortable withholding information from parents should tell the young person to find another doctor.
She says: “We are very sensitive to the rights of young people, but we also need to be sensitive to the rights of the parents who have brought them into the world and devoted their lives to them for 14 or 15 years. And, ultimately, it will almost certainly be the parents who will keep these children alive in such difficult, complex situations.”
But professionals working with adolescents emphasise the importance of confidentiality in maintaining the young person’s trust. Dr Danielle Mazza, medical director of Family Planning Victoria, says young women seeking advice about an unplanned pregnancy, for example, “often tell you they have enormous fear of reprisal, of being kicked out in the street. One of the reasons they come to see us is because of the confidentiality we offer them”.
The association’s policy is that if a young woman has sufficient awareness of the issues to seek out counselling, she also has sufficient awareness to make her own decision.
Dr Margaret Kilmartin, president of the Australian College of General Practitioners, says difficult issues with underage adolescents are a constant part of the GP’s work, with underage pregnancy one of the most common problems.
Nothing good would come of breaching confidentiality, she says, and doctors would be obliged to do so only if the situation involved danger to the patient or society.
While doctors should not usually ring up the family, they should encourage the young person to reach out: “You work with the young person to see if they can bring themselves to confide in their parents. The major problem for a lot of these young people is that there are no parents available to them.”
Dr Kilmartin believes troubled adolescents tend to seek her out partly because she is female. Bartholomew’s study confirms female doctors are twice as likely as males (15 per cent compared with 7.4 per cent) to report often facing decisions about underage competence.
That may be partly due to another of the study’s findings: that there is a gender gap in attitudes to young people. Female doctors (and younger doctors) were generally more likely to be liberal. Ninety per cent of female doctors found “Liz” competent to request a prescription for the pill, compared with 76 per cent of males. “Liz” was found competent by 97 per cent of doctors aged 25-34, but only 56 per cent of doctors aged over 55.
Bartholomew intends to follow up the survey with focus groups of interested doctors to discuss the issues and help him formulate, with the Centre for Adolescent Health, written guidelines for doctors to use.
He warns, though, that no guideline can cover every eventuality, and that no matter how carefully “objective criteria” are applied, in the end, individual doctors will still have to make personal judgments: “There will always be a subjective element
to the decision.”
First published in The Age.