AMA Journal of Ethics^®

Opinion 5.055 - Confidential Care for Minors

Physicians who treat minors have an ethical duty to promote the autonomy of minor patients by involving them in the medical decision-making process to a degree commensurate with their abilities.

When minors request confidential services, physicians should encourage them to involve their parents. This includes making efforts to obtain the minor’s reasons for not involving their parents and correcting misconceptions that may be motivating their objections.

Where the law does not require otherwise, physicians should permit a competent minor to consent to medical care and should not notify parents without the patient’s consent. Depending on the seriousness of the decision, competence may be evaluated by physicians for most minors. When necessary, experts in adolescent medicine or child psychological development should be consulted. Use of the courts for competence determinations should be made only as a last resort.

When an immature minor requests contraceptive services, pregnancy-related care (including pregnancy testing, prenatal and postnatal care, and delivery services), or treatment for sexually transmitted disease, drug and alcohol abuse, or mental illness, physicians must recognize that requiring parental involvement may be counterproductive to the health of the patient. Physicians should encourage parental involvement in these situations. However, if the minor continues to object, his or her wishes ordinarily should be respected. If the physician is uncomfortable with providing services without parental involvement, and alternative confidential services are available, the minor may be referred to those services. In cases when the physician believes that without parental involvement and guidance, the minor will face a serious health threat, and there is reason to believe that the parents will be helpful and understanding, disclosing the problem to the parents is ethically justified. When the physician does breach confidentiality to the parents, he or she must discuss the reasons for the breach with the minor prior to the disclosure.

For minors who are mature enough to be unaccompanied by their parents for their examination, confidentiality of information disclosed during an exam, interview, or in counseling should be maintained. Such information may be disclosed to parents when the patient consents to disclosure. Confidentiality may be justifiably breached in situations for which confidentiality for adults may be breached, according to Opinion 5.05, “Confidentiality.” In addition, confidentiality for immature minors may be ethically breached when necessary to enable the parent to make an informed decision about treatment for the minor or when such a breach is necessary to avert serious harm to the minor.

Opinion 2.015 - Mandatory Parental Consent to Abortion

Physicians should ascertain the law in their state on parental involvement to ensure that their procedures are consistent with their legal obligations.

Physicians should strongly encourage minors to discuss their pregnancy with their parents. Physicians should explain how parental involvement can be helpful and that parents are generally very understanding and supportive. If a minor expresses concerns about parental involvement, the physician should ensure that the minor’s reluctance is not based on any misperceptions about the likely consequences of parental involvement.

Physicians should not feel or be compelled to require minors to involve their parents before deciding whether to undergo an abortion. The patient, even an adolescent, generally must decide whether, on balance, parental involvement is advisable. Accordingly, minors should ultimately be allowed to decide whether parental involvement is appropriate. Physicians should explain under what circumstances (e.g., life-threatening emergency) the minor’s confidentiality will need to be abrogated.

Physicians should try to ensure that minor patients have made an informed decision after giving careful consideration to the issues involved. They should encourage their minor patients to consult alternative sources if parents are not going to be involved in the abortion decision. Minors should be urged to seek the advice and counsel of those adults in whom they have confidence, including professional counselors, relatives, friends, teachers, or the clergy.

Opinion 2.12 - Genetic Counseling

Three primary areas of prenatal genetic testing are (1) screening or evaluating prospective parents for genetic disease before conception to predict the likelihood of conceiving an affected child; (2) analysis of a pre-embryo at the preimplantation stage of artificial reproductive techniques; and (3) in utero testing after conception, such as ultrasonography, amniocentesis, fetoscopy, and chorionic villus sampling, to determine the condition of the fetus.

Physicians engaged in genetic counseling are ethically obligated to provide prospective parents with the basis for an informed decision for childbearing. Counseling should include reasons for and against testing as well as discussion of inappropriate uses of genetic testing. Prenatal genetic testing is most appropriate for women or couples whose medical histories or family backgrounds indicate an elevated risk of fetal genetic disorders. Women or couples without an elevated risk of genetic disease may legitimately request prenatal diagnosis, provided they understand and accept the risks involved. When counseling prospective parents, physicians should avoid the imposition of their personal moral values and the substitution of their own moral judgment for that of the prospective parents.

The physician should be aware that where a genetic defect is found in the fetus, prospective parents may request or refuse an abortion. Physicians who consider the legal and ethical requirements applicable to genetic counseling to be in conflict with their moral values and conscience may choose to limit their services to preconception diagnosis and advice or not provide any genetic services. However, the physician who is so disposed is nevertheless obligated to alert prospective parents when a potential genetic problem does exist, so that the patient may decide whether to seek further genetic counseling from another qualified specialist.

Genetic selection refers to the abortion or discard of a fetus or pre-embryo with a genetic abnormality. In general, it is ethically permissible for physicians to participate in genetic selection to prevent, cure, or treat genetic disease. However, selection to avoid a genetic disease may not always be appropriate, depending on factors such as the severity of the disease, the probability of its occurrence, the age at onset, and the time of gestation at which selection would occur. It would not be ethical to engage in selection on the basis of non-disease-related characteristics or traits.