Editor’s Note: This column presents a problematic case that poses a medical-ethical dilemma for patients, families, and healthcare professionals. As it is based on a real case, some details have been omitted in the effort to maintain patient confidentiality. In this case, the doctor discusses her experience from the retrospect of the unanswered question.
Column Editor: Ferdinand D. (Nick) Yates, MD, MA; Professor of Clinical Pediatrics, State University of New York at Buffalo
How should a physician respond to multiple-party claims of authority?
Some Fridays are more memorable than others. This one started with a pile of phone messages, and my nurse said that the one on top was urgent. The patient—age seventeen—said she had to come in immediately and talk: “I’m desperate. And please do not let my mom know. I might be pregnant, I need your help.” The patient’s mother had also called. I requested that the nurse make arrangements without notifying the mother, as I would call later.
The patient arrived during my lunch hour, since it was the only time available, and was frantic, as she was certain that she was pregnant. Her menstrual period was late, and, indeed, urine testing confirmed her pregnancy. Based on the timing of her last period she was about eleven or twelve weeks along. The patient said that her mom would pressure her to get an abortion. We talked for a long time about what she wanted, if the father of the child was to be involved, and the challenges to be faced. I also informed the patient that her mother was already aware of something as she had also called to talk to me. I asked how she would like me to handle things with her mother since I would need to return her phone call from earlier in the day. The patient already knew that her mother was suspicious and recognized that the discussion was both necessary and appropriate. The patient was willing to see a counselor and an obstetrician on the following Monday for confirmation of dates via ultrasound. She wanted me to help her speak with her mother and said that I could invite her to come in Monday for a joint discussion. The patient thought letting things settle over the weekend was the best course of action. The immediate next step was for me to tell her mother that we would all talk the following week and that her daughter was medically fine and getting all the care she needed.
Things seemed to have the potential to move forward, and just as I was about to take a quiet moment at the end of the day to call the teenager’s mother, the assistant medical director for our multi-specialty clinic stormed into my office. He irately informed me that there had been a severe patient complaint that he needed to address with me immediately. Apparently, a patient of mine was being denied access to care in violation of her reproductive rights, and what did I think I was doing? A mother who had called about her daughter was livid because she was certain her daughter was almost at the twelve-week limit when an abortion could be done locally and with less risk to her daughter. She said that she had informed the director “that the treating physician was making things worse.” Somewhat shaken, I asked the name of the patient, and, sure enough, it was the adolescent female with whom I had spoken this morning. I informed my medical director that I had seen the patient, that she was pregnant, and that she had told me she wanted to keep the baby. When he heard about the proposed plan of action, he felt less concerned about the issue of “denial of access to care” and—given the full picture—did not have risk management concerns at this time.
This case documents four distinct perspectives regarding patient care: that of the patient, the physician, the patient’s parent(s), and the medical administration. In some cases, these perspectives exhibit little divergence, but on most occasions our greatest medical conundrums arise from the conflict of two or three of these positions.
This case highlights the physicians often face in practice when they seek to balance the competing and sometimes conflicting notions of confidentiality, veracity, and fidelity. The pregnant teenager (even as a minor) has certain mandated privileges—state and federal—that entitle her to a variety of medical care services without the consent or even the knowledge of her parents. How does the treating physician resolve conflicts between the parent’s values and those (rights or values) of their minor child? What does it mean to respect the family’s values? What harm may come to the child as a result of disrupting a stable system of social support provided by the family? What does an individual do if he or she, as the physician, has a conflict with the course of action chosen by a patient or a parent or, on the other hand, if the employer has a conflict with the medical course of action the physician deems appropriate? The physician’s fiduciary responsibility consists of transparent competent care that is free of coercion.
In this case, the professional duty to the patient for confidentiality was in potential conflict with the duty to tell the parent the truth. In general, this special challenge is more common in pediatrics, in which case the pediatrician has a legal obligation to the parents (or legal guardian) and a moral obligation to appropriately protect the patient’s privacy. In pediatrics, parents are assumed to be appropriate decision makers for their children and most agree that parents deserve wide latitude in determining what is best for their children. This includes determining their own families’ values and teaching the children according to these principles. Respecting a family’s values means recognizing that parents have the primary role in helping to define what constitutes their child’s well being and their child’s understanding of the “good.” Our legal system provides options for physicians in cases in which parents are incompetent. In addition, we also understand that young children are unable to make decisions. However, the fact is that children outgrow their dependent states. As maturation progresses and a child’s ability to understand information increases, the parent has a moral obligation to honor the child’s specific perspective, which may lead to a conflict between the parents’ notion of what is best for the child and the child’s own view of what is best for himself. This potential conflict occurs in multiple domains, not just in the area of reproductive health.
There was little doubt, in this case, that the mother (as the patient’s parent and guardian) had “guessed” what was going on, given her calls to the physician and the medical director. However, this does not diminish the challenge of supporting the patient who is not a mature minor, is not of legal age, and disagrees with her mother on the best course of action. This patient stated, “My mom will kill me if I do not have an abortion,” (an ironic comment as two would be killed instead of only one). But in fact, the mother was presumably primarily concerned about the emotional and social chaos, the profound disappointment, and the sense of loss the news would bring, rather than the actual physical harm. The effort to schedule time with both mother and daughter provided an opportunity to both support the patient and to fully disclose difficult information. In settings in which a physician has concerns about addressing these conflicts, inviting a behavioral therapist and social worker to attend the meeting can be very helpful.
This case also illustrates the conflicts that might arise (at the administrative level) between employers and physicians who have moral objections to a legally available procedure—such as abortions. The physician does have the duty to engage with patients and families about controversial matters such as abortion. This does not mean that the physician must bow to requests to carry out an action that she finds morally offensive. In this case, my moral objection to abortion was known to both my employer and my patients. Not surprisingly, full disclosure minimizes but does not eliminate the potential for conflict. As this case demonstrates, the mother was concerned enough about my position on abortion to call the medical director, and the daughter felt welcome enough to request my assistance. In my opinion, the moral integrity of a physician is reinforced by being open about her moral boundaries and not hiding information. If there is an irresolvable conflict, physicians retain the right to transfer a patient to the care of another competent physician. Respect of patients and their families is a cornerstone of the therapeutic relationship, and respect should be maintained even in settings in which physicians may disagree with a patient’s or family’s decision.
This case also highlights the need for strong communication skills, something which is, sadly, more often “caught than taught” in medical school curriculums. Effective communication addresses the cognitive need of both the parent(s) and patient to know and understand as well as the emotional needs of both parties to feel known and to be heard and understood. While effective communication cannot resolve all conflicts, it can substantially impact the physician’s ability to actively demonstrate care for a patient even if there are areas in which a physician entertains the possibility of transfer of patient care.
To the chagrin of this physician, the patient was lost to my follow-up care. I do not know if the infant’s life was allowed the opportunity to flourish or if it was terminated.
This case represents how a particular medical-ethical problem can generate perceived individual autonomy and directed persuasion from each of several perspectives. Each viewpoint—parental (often protective, but occasionally overbearing), physician (often supporting patient rights, but sometimes engaging in personal right of conscience discussions), and administration (citing legal and societal claims)—will each align with some aspect of the patient’s best interest and simultaneously may aggrandize its specific perspective.
The challenge for the practicing physician is to direct a clinical path that exercises professional fiduciary care for the patient while offering proper respect for parental authority and appropriate adherence to the administrative underpinnings, along with being able to exercise her individual right of conscience. This process generally demonstrates compassion and may conjure up compromise, but it always demands genuine care for the patient. The physician’s responsibility is to the patient who asks for his or her help and somehow the physician needs to honor that relationship even in the face of substantial challenges from other people and aspects of the patient’s healthcare needs.
AAP, Committee on Bioethics. “Communicating with Children and Families: From Everyday Interactions to Skill in Conveying Distressing Information”. Pediatrics V. 121 N.5, May 2008:e1441–e1460.
AAP, Committee on Bioethics. “Informed Consent, Parental Permission, and Assent in Pediatric Practice”. Pediatrics V. 95 N. 2, February 1995:314–317.
Cantor, JD. “Conscientious Objection Gone Awry—Restoring Selfless Professionalism in Medicine”. N Engl J Med. (2009). 360:1484–1485.
Curlin, FA, et al. “Religion, Conscience, and Controversial Clinical Practices”. N Engl J Med. (2007). 356:593–600.
Sulmasy, DP. “What is Conscience and Why Is Respect for It So Important?” Theor Med Bioeth. (2008). 29:135–149.
Editor’s Note: This case study originally appeared in Ethics & Medicine: An International Journal of Bioethics 27, no. 2 (2011): 75–78 and is used with permission.
