Ethics Quiz And Poll: The Nurse Practitioner’s Dilemma

Sure.

It is seldom that I strongly disagree with NYU philosophy professor Kwame Anthony Appiah, “The Ethicist” of the New York Times Magazine’s long-running advice column. A month ago I did, and emphatically so.

The question posed to him involved a professional ethics dilemma, and “The Ethicist” was so certain he had the correct answer that he was uncharacteristically terse about it. I’m pretty certain about the answer too, except that my certainty is that he’s wrong. But I have some doubts, based on my ethical positions in related situations.

The inquirer was a a nurse practitioner working at a primary care clinic for low-income patients. She said that a 16-year-old patient told her that she had stopped coming by the clinic to have her birth control pills replenished because she and her partner were trying to have a baby together. She had been having unprotected sex for  a while, and she was concerned that she might have some physical problem preventing her from conceiving. The nurse practitioner asked,  “Would it be ethical for me to steer her away from trying to get pregnant? …Or, as her health care provider, do I have an ethical duty to try to help her conceive?”

Appiah doesn’t see any wiggle room. He says,

“You’re her health care provider. You should certainly tell her about the medical consequences of pregnancy. But the social and economic consequences don’t fall within your professional competence. An intervention about her life choices may seem moralizing and intrusive to her, and it could drive her away; and then she’d be losing your guidance on the things you are trained to help her with.”

Really?

We are told that the woman 1) is 16, 2) is not attending school, 3) is unemployed, 4) is not married, and that her “partner” has a “steady job,” whatever that means. Moreover, regardless of how steady a job he has, the partner, assuming he is an adult, is committing a couple of crimes, including statutory rape. On a more mundane level, however steady it may be, his  job is not so well-paying that his intended baby-mama can get her medical care somewhere other than a clinic for low-income patients. I would add, though this might be harsh, that the young woman is naive, ignorant, and quite possibly not very bright. The nurse practitioner would be, in my view, professionally and from a general ethics perspective negligent not to explain to the girl why having a child under these conditions is irresponsible and reckless.

My position is informed by my professional ethics perspective which is, admittedly, heavily influenced by specializing on legal ethics. Though ethics priorities differ among the professions, the basic principles are the same. All professions exist to benefit society and human beings generally. In the ethics rules/guidelines lawyers must follow,  ABA Rule 2.1, on the topic of advice, states,

In representing a client, a lawyer shall exercise independent professional judgment and render candid advice. In rendering advice, a lawyer may refer not only to law but to other considerations such as moral, economic, social and political factors, that may be relevant to the client’s situation.

A Comment adds,

Advice couched in narrow legal terms may be of little value to a client, especially where practical considerations, such as cost or effects on other people, are predominant. Purely technical legal advice, therefore, can sometimes be inadequate. It is proper for a lawyer to refer to relevant moral and ethical considerations in giving advice. Although a lawyer is not a moral advisor as such, moral and ethical considerations impinge upon most legal questions and may decisively influence how the law will be applied.

I see no reason, ethically, logically or practically, why this should not apply to other professionals as well. The second reason I find Appiah’s advice inappropriate in this situation is the Ethics Alarms principle, “If circumstances place you  in the position to fix a problem, and you have the ability to do so,  fix it. Don’t look for reasons to pass the buck.”

It doesn’t require professional  economic or societal expertise to recognize that the girl’s plan is a recipe for disaster. The nurse is the one currently in a position to—perhaps— save the young woman from a life-wrecking choice. She has an obligation as a human being, not merely a medical professional, to make the effort. So what if the advice seems “moralizing and intrusive” to the girl? Find a way to get her to listen. If the nurse drives her away, the girl is in no worse straits than she is already. Find her a counselor.  Make the effort to see that she talks to someone skilled and persuasive.Do something.

Do not help her get pregnant. Nurses are also bound by the general ethical edict not to do harm. Harm is not always defined by the patient, as the “Please cut off my arm, it is possessed” cases show. It is objectively harmful for this young woman to get pregnant in the situation presented. You don’t need a professional certification to make that call. You need a modicum of awareness, a functioning cerebrum, and courage.

The fact that this case involves the criminal exploitation of a minor and a sex crime makes it easier for me than if the young woman were past the age of consent. The position here on Ethics Alarms regarding doctors, nurses and pharmacists refusing to do their jobs because they have moral objections to an individual’s  need, be it a birth control prescription, an abortion or a same sex marriage is that their ethical options are to so their jobs or  find another field, unless they received consent for their conscientious objections at the time they were employed. But the objection to the 16-year-old’s plan doesn’t have to be moral; it’s objectively wrong on practical grounds. The fact that the nurse would also be assisting in the corruption of a minor and allowing statutory rape to continue takesrefusing to help the girl get pregnant  out of any professional obligations, or should.

Your Ethics Alarms Ethics Quiz to begin this Tuesday is..

Who’s right, “The Ethicist,” or this ethicist?

And because I am curious about how the opinions are distrubuted, here’s a poll:

58 thoughts on “Ethics Quiz And Poll: The Nurse Practitioner’s Dilemma

  1. “But the social and economic consequences don’t fall within your professional competence”

    Bullshit. I saw a nurse practitioner for my primary care for years. Among the questions she would ask about my general health were also questions like: “How are things at home?”, “How are the kids doing in school?”, and “How is your husband’s new job working out?”. She understood quite clearly that my social and economic welfare had a direct effect on my physical health. How does Appiah not get this?

    • Jack, you are absolutely correct! My Primary care doc also treats other members of my family, and any visit is a catch-up on everyone. The range of issues we have discussed is formidable. She was especially concerned with my mental well-being while I was confined to a wheelchair for thirteen months, and all the ramifications thereof. She periodically emails me links to information on managing my health issues.
      On the other hand, it was same-same for my attorney of many years, a former ADA who left that field to start his own practice. He was only a few years my senior, but nonetheless mentored me in many ways. An outstanding gentleman and attorney.

  2. While she is of the age of consent to have sex, she is not yet an adult.

    Technically speaking, statutory rape is not a factor at. In Connecticut, for instance, the age of consent is 16 – not that this meaningfully impacts the ethical and practical aspects of the situation. It is a perplexing situation, where a 16-year old kid could legally have a baby with a 40 year old, but not attend a Rated-R movie at the theater by herself.

    The age of consent here only applies as to whether it triggers the practitioner’s mandatory reporter obligation. Other than that, I agree that steering women away from pregnancy, is the ethical path.

    • I am troubled though about the potential medical consequences. If the girl had a treatable condition leading to infertility, delaying treatment could complicate future pregnancy when she is mature enough to be a mother. There is a real medical obligation to diagnose a potential disorder at conflict with the human obligation to guide the woman away from an unhealthy and potentially disastrous decision. I think there has to be a two fold approach where the practitioner counsels the patient, while meeting whatever ordinary standard of care obligation she might have.

  3. Yikes. I know you hold Appiah in high regard, and your previous posts about his work make clear why. But I agree with you – he’s very much in the wrong on this one.

    Many years ago, I worked in a group home for adjudicated teenagers. We had several 15 and 16 year old girls who, like the girl in question, actually wanted to become pregnant (thank God none of them managed to achieve this goal on our watch).

    I recognize that my sample size is small enough that this is nothing more than anecdotal – but as far as I’m concerned, well-adjusted 16-year-old girls may adore babies and kids but understand that now’s not the time. To desire pregnancy at that age requires one or more underlying pathologies.

    Our clients had all manner of issues, but in the case of these girls, there was a misplaced ideation that the nurturing and care they were denied in their own lives could be re-claimed if directed towards a baby. In other words, these kids were hoping to amend their own loss by showering attention and love on their own kids – to give someone else what they, themselves, weren’t offered.

    That’s a rather romantic idea, and one could argue that the desire is, in a sense, a rather sweet way to attempt to cure a terribly cruel factor in their own lives. Certainly, it’s better than stalking their own mothers and taking physical revenge.

    But it’s irrational. It should come as no surprise that among other things, these girls were poor students who lacked many of the skills required of normal everyday life – even for well-functioning teenagers. One was a cutter. Another had substance abuse issues. And so on.

    Appiah is completely wrong here. Helping the girl get pregnant is a nearly certain way to destroy at least two lives.

    • Thanks Arthur. Awesome observations based on invaluable first hand experience. Being a writer, I find anecdotal evidence is the best evidence. Comment of the Day worthy.

  4. I think it’s clear; “Counsel the girl, but refuse to help her get pregnant.”. In addition if the nurse practitioner has any suspicion that statutory rape is involved then she is obligated to report it.

    Side note: usually a nurse practitioner working in a primary care clinic is not likely to have the specific knowledge required to find out why the girl is not getting pregnant, there are specialists in the medical profession that deal with in infertility problems. The nurse practitioner has a really easy out.

    • >The nurse practitioner has a really easy out.

      I don’t think it’s that easy. What if the girl asks for a referral? Is she obliged to withhold the referral? Or does she buck the ethical duty to counsel the girl against pregnancy to the specialist?

      • Rich in CT wrote, “I don’t think it’s that easy. What if the girl asks for a referral? Is she obliged to withhold the referral? Or does she buck the ethical duty to counsel the girl against pregnancy to the specialist?”

        Think this through to its logical conclusion. The nurse practitioner can easily advise the patient against getting pregnant and still refer the patient to a specialist. Here’s the catch; what ethical infertility specialist is going to take on a 16 year old minor patient that wants to get pregnant that can’t? The nurse practitioner isn’t likely qualified to give medical advice about infertility so ethically she should defer the patient to a specialist and ethical infertility specialists aren’t likely to take on a 16 year old minor as a patient – doesn’t that sort of solve the problem?

        Of course none of this properly addresses the issue as to why the hell a 16 year old teenager want’s to get pregnant; is she trying to keep her man by trapping him, does she want money from the state, does her man know that she’s trying to get pregnant, is her man an adult and is this a possible statutory rape situation, is the patient an emancipated teenager, etc, etc.

        • The fertility expert has the same conundrum as the clinician. The teen has an unknown potential condition causing infertility. Most wouldn’t learn about such a condition until later, when it may be more difficult to treat. She might also be perfectly healthy and timing things wrong (her partner might also have a secret vasectomy). The duty to do no harm is double edged here: doing nothing may cause harm by leaving a condition untreated, doing something may lead to irresponsible pregnancy. How does a doctor, after counseling against pregnancy at this stage, refuse at least evaluation in this scenario?

          • Rick in CT wrote, “The fertility expert has the same conundrum as the clinician.”

            No they don’t; Doctors are not required to take on new patients.

            Rick in CT wrote, “The teen has an unknown potential condition causing infertility. Most wouldn’t learn about such a condition until later, when it may be more difficult to treat. She might also be perfectly healthy and timing things wrong (her partner might also have a secret vasectomy). The duty to do no harm is double edged here: doing nothing may cause harm by leaving a condition untreated, doing something may lead to irresponsible pregnancy.”

            And maybe the girl is just plain stupid and the man in her life is wearing a condom. Lots of what if’s. 😉

            The fertility clinician does not know if a condition actually exists when the 16 year old patient is refereed to them, they just know that the patient is 16 years old, wants to get pregnant and isn’t getting pregnant. What if the patient is 13, 14 or 15 years old; when should Doctors should start paying attention to the glaring obvious red flags that are waving in their face. The fertility specialist Doctor does no harm either legally or morally by not taking on this new patient.

            Rick in CT wrote, “How does a doctor, after counseling against pregnancy at this stage, refuse at least evaluation in this scenario?”

            For the Nurse Practitioner, “I’m sorry, we don’t provide those services at this clinic.”

            For the fertility specialists, “I’m sorry, we don’t have any appointment openings for new patients until 2022”.

              • Yes, an individual practice might be able to refuse a patient. A fertility specialist might even have a minimum age policy that precludes a 16 year old. However, this is ducking the issue.

                The original nurse practitioner has a professional obligation to evaluate her patient for fertility issues, or find someone qualified to do so. This is the barest standard of care. If a standard gynecological health evaluation does not reveal any obvious dysfunction, then no further obligation to offer treatment exists.

                However, if a disorder is found, the options for treatment, and potential consequences, must be discussed. Again, this is the barest standard of care. If the patient does not qualify for treatment due to her age, the practitioner has a duty to inform her patient. Lying to the patient to patient and claiming that the practitioner does not offer these services is professional misconduct. The practitioner might even refuse to offer treatment herself after discussing the options, but she must balance the risk of delaying treatment, against the risk the patient may act irresponsibly.

                If a clinic is going to presume to give people under the age of 18 birth control and sexual health advice, they are ethically estopped from objecting to evaluating the sexual health of a patient. At a minimum, they have a duty to evaluate and diagnose, and discuss treatment options if applicable.

                • Rich in CT wrote, “The original nurse practitioner has a professional obligation to evaluate her patient for fertility issues, or find someone qualified to do so.”

                  Again; this nurse practitioner (NP) is at a “primary care clinic” and most likely a general medicine NP of some sort with no specific expertise in fertility medicine, she is only obligated to give treatment in areas that she is qualified, beyond that they refer to medical Doctors or specialists. That’s specifically why I wrote in my original comment “usually a nurse practitioner working in a primary care clinic is not likely to have the specific knowledge required to find out why the girl is not getting pregnant, there are specialists in the medical profession that deal with infertility problems.”; did you honestly miss that part of my comment?

                  I think you maybe assuming that I’m saying that the NP should deny standard gynecological health evaluation, I’m not saying or implying anything of the sort, in fact those kind of evaluations are pretty standard for teenage girls and my understanding is that they become very important when they become sexually active and placed on birth control. Of course the NP should treat the patient for medical conditions that they find in regular evaluations as long as they are qualified to do so, NP’s can’t do everything. I don’t think anyone is suggesting denying basic medical treatments that are within their capabilities.

                  Honestly, I think we’re not too far apart on this.

        • Agreed. Why does this 16-year-old want to get pregnant? There’s a deeper story there, and an adolescent’s general inability to see beyond an immediate goal. Absent her man, where will she be at 18, 20, 25, 35 — trying to negotiate an already tenuous life with a child in tow. If she were already pregnant that would be an entirely different issue. But as of this writing, she has some (face it) moronic pipe dream about parenthood, especially in straitened circumstances. It is absolutely the duty of the P.A. to walk her through this, or find someone who will help her see the dreary future she may face.

  5. Remember, he is ‘The Ethicist’, not ‘The Moralist’. I like how ‘moralizing’ is an unforgivable sin and a forbidden act.

      • I did qualify my statement.

        Would you tolerate a medical professional refusing to help a 26-year-old based on age? Can you find a non-subjective way to require helping at 26 and not 16? Sexually mature and of age to consent, yes? Presumed mentally competent, yes?

        The nurse practitioner is left with only the ick factor. Professional, not personal ethical considerations control.

    • As a physician, I’m provisionally with valkygrrl. The default position would be to assist the girl; refusing would be the exception.

      That said, my approach would involve extensive counselling and discussion, as it would with any patient requesting anything that I think, medically, might not be a good idea: opioids for back pain, surgery for reducible hernia, cholinesterase inhibitors in severe dementia, etc.

      As much as the face of this situation (16-year-old, apparently low-income individual desiring pregnancy) also alarms me, I wouldn’t jump to conclusions without collecting additional information.

      Possibly importantly, where I practice, there is no formal age of medical majority and determining competence (to make medical decisions) is a physician ‘s duty. This includes deciding whether a mentally ill person can make decisions about their healthcare and whether a “minor” can do so. Competence allows a patient to give informed consent, which requires the person to demonstrate understanding of the benefits and risks, alternatives and ultimate consequences. Competence is tied to the decision being made: one child might be deemed able to choose an antibiotic but not to get fertility treatment.

      If I determine this girl to be competent to decide to get fertility treatment, she gives informed consent AND I am not convinced the outcome would be ruinous, my professional (and moral duty) would be to medically assist her AND throw every social, familial and community support I can at her. She may be a remarkably mature 16-year-old, and as much as I may privately judge her choices, I wouldn’t professionally do so at this point.

      If I’m worried, then we talk more, likely over multiple visits over multiple weeks, while we get some of the technical stuff out of the way: start prenatal vitamins, get an ultrasound, etc. Either I become convinced that she’s actually good to do this or she becomes convinced that she should delay (or I successfully stall her for several years…?). If we continue to disagree, then I will tell her so and she will leave to seek care elsewhere.

      This last situation is the dreaded “drive her away” scenario described by the Ethicist. She may seek care with a medical professional less interested in her total health, a complementary or alternative medicine practitioner of whatever quality of Dr Google, leading to negative consequences.

      Especially in this situation, as described, the girl is already trying to get pregnant on her own. I don’t see “refusing” to assist her as a viable option at all. I don’t see how any reasonable practitioner wouldn’t predict that, if refused point-blank, she’d just go door to door until she found a careless MD who just gives out prescriptions for a living.

      Separately, confidentiality laws prohibit me from discussing this with anyone else without her permission. Again, where I practice, if she’s 16 and he’s at least 14, this is a legal relationship and I don’t have a legal duty (nor confidentiality exception) to report.

    • Huh? Race, socioeconomic status, or sexual orientation or gender identity are not involved in the decision at all. Marital status, age plus gender (not “gender identity,: which means something else) and educational achievement are the issues. Nor is counseling “discrimination.”

      • Would you really have had me not quote the whole paragraph?

        Martial status and educational achievement fall under Socioeconomic statue.

        Age only factors if the union is unlawful or the body is not full sexually mature.

        You might want to check where unwed pregnant 16-year-old rates on the cognitive dissonance scale and then take a deep breath or three before considering a reply.

        • You might want to learn the distinction between “discrimination” and dealing with the actual circumstances of the case. Counseling a girl in that collection of circumstances is not discrimination by any legal definition of the word. A nurse might face santions for withholding the desired treatment, but not for “discriminating” in the legal sense.Your argument makes no sense, because you can’t, I guess, see the clear distinction between recognizing that it is a duty to try to prevent an at-risk child from becoming an unwed pregnant mother with no skills and no sources of income when her asshole “partner” finds a nice slim, 17 year old to shack up with, and looking down tghe scale at a an unwed teen mother. Lawyers are similarly required not to discriminate, but they can and do advise juveniles to take different courses than adults, and poor clients to make different choices than rich ones.

          You also need to take a deep breath before patronizing me. I don’t appreciate it, I don’t deserve it, and I won’t tolerate it indefinitely.

          • Not counseling someone before making a foolish decision is actually disrespectful of the person. Trust that they’d want to make the most informed opinion possible, treat them as you’d want to be treated. Just as we are not obligated to keep our mouths shut when we see someone careening into a reckless choice, they to are not obligated to consider our counsel.

            But no harm is done by giving the counsel.

            There’s no way this could be called discrimination.

          • A nurse might face [sanctions] for withholding the desired treatment

            And there’s your answer, the same as mine, the same as Tony’s above. Professional medical ethics says the nurse practitioner can’t refuse.

            The rest is either emotion or ethical considerations for non-medical professionals. Your quiz is not a question about the ethics of encouraging unwed teenagers to become pregnant or of standing by and allowing it to happen. Of course it’s an awful life-shattering mistake of epic proportions but your own reference to legal ethics here and in the past admits that professional ethics codes override the personal when acting in a professional capacity.

            • Of course she can refuse, and in this case, should. She might not enjoy the consequences, but she can do what she deems to be the right thing, hence the “quit” option.Just as the stories I’ve written about where lawyers breached their ethics rules to save lives, and, in most cases, the disciplinary boards blinked. See “The Ethics Incompleteness Principle.” It’s a tag.

              • On the flip side…should medical professionals be able to refuse treating teenagers who identify as a particular gender and wish to receive hormones and surgeries that permanently obliterates their fertility? This is happening to thousands of young people, yet this ethics issue isn’t discussed much.

              • The “quit” option, as provided in the quiz and discussed in several comments, doesn’t pass muster with me.

                I’ve never been in the 16-year-old-desiring-pregnancy situation, but I’ve been in the opioid-misusing-heart-disease-patient, iridology-for-cancer, CPR-for-brain-dead-relative boats before, just to name a few. The facile solution is to “quit” (or, more practically, “fire” the patient for irreconcilable differences). Again, this leads to patients seeking care elsewhere, whether with a less principled practitioner, a nonregulated health professional or some quack on the street.

                It is obviously not ideal for the patient and I don’t see how it would clear the practitioner’s conscience, either.

    • The ethics opinion cited by valkygrrl is focused on the issue of assisted reproductive technology which includes procedures such as in vitro fertilization, and does not directly address the issue of treating minors for reproductive issues. That specific issue is addressed directly in “AMA Code of Medical Ethics’ Opinions on Confidential Care for Sexually Active Minors and Physicians’ Exercise of Conscience in Refusal of Services”.

      “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.

      The portion of the AMA code cited does not directly answer the question of whether it would be ethical to steer her away from trying to become pregnant. However, there is another section of the code regarding informed consent which does apply. Basically both medical ethics and the law require that patients must be provided enough information about any proposed treatment to allow them to provide informed consent. Pertinent information includes the risks and benefits of treatment, other treatment options, and the consequences of not accepting treatment. Providing information regarding the risks of pregnancy might steer the patient away from trying to become pregnant but the AMA guidelines on medical ethics and the law require it. This has nothing to do with moral beliefs and is strictly based on the requirement that a patient be provided enough information to allow them to make an informed decision.

      The AMA code cited above specifically addresses the issue of ethics in providing care to sexually active minors. What of the question of helping her conceive? The code specifically addresses sexual care issues of contraception, pre and postnatal care, pregnancy testing, and delivery services but does not directly address actively helping the patient conceive. Because the code specifically includes a number of services, if it was intended to cover fertility services then they would be mentioned also.

      As a general rule, Florida law requires a minor who seeks medical treatment
      to obtain the consent of a parent or guardian but there is a list of “specific medical care” for which minors may give consent. In the area of sexually related care are listed contraception information and services including the morning-after-pill, pregnancy testing, and prenatal care. Fertility treatment is not a specific medical care for which a minor may give consent. The AMA code and the Florida health care laws both allow minors to consent to birth control and services to care for a pregnancy but do not allow minors to consent to fertility treatment. There is no ethical duty to try to help the patient conceive and, at least in Florida, if the practitioner provides fertility treatment she would be breaking the law by providing a treatment for which there was no legal consent.

      I enjoyed Tony’s comment and for the most part agree with the points he makes. I would point out though that in Florida if he did not refuse to assist her and instead provided specific treatment to help her become pregnant he would be breaking the law. This would not preclude treating other medical conditions such as hypothyroidism that might impair fertility as one of their consequences. Also in Florida, a minor cannot give legal consent for an antibiotic except to treat a sexually transmitted disease. Treatment of sexually transmitted diseases is in the list of specific medical care for which a minor may give consent but treatment of other infections is not. Of course, treatment of an infection or hypothyroidism does not generally present the same problem in getting parents involved as sexual issues do. It is an oddity in the law that a minor may consent to care for most sexual issues, mental health treatment, and drug treatment without parental involvement but cannot consent to treatment for an ingrown toenail or acne.

      The code stresses that every effort be made to persuade the minor patient to involve the parents but states that the provider may ethically treat the patient without involving the parents. However the code does not absolutely forbid the provider breaking confidentiality and involving the parents against the wishes of the minor patient provided the practitioner feels there would be a serious health threat if the parents were not involved and the parents would be helpful. The code also allows a provider who has reservation about providing a treatment without parental consent to make an appropriate referral instead.

      Based on medical ethics and the law, the provider’s ethical course would be to make every effort to involve the parents or guardian with the consent of the patient, provide education about the risks of pregnancy, encourage her to get back on her birth control, refer her to a qualified psychotherapist, refuse to assist her in getting pregnant, and if the practitioner feels that without parental involvement there is a serious health risk and that parental involvement will be helpful then break confidentiality and involve the parents.

  6. Dicy. Let’s not kid ourselves, these free and low-income clinics are often a relatively easy source of cheap or free and confidential reproductive health care for 16-17yo girls whose homes are broken or who want to run around on their parents. Let’s also not kid ourselves, 16-17yo girls often make rash or emotion-based decisions. Let’s assume that the girl is on the level, and she and her “partner” actually want to have a baby, rather than her wanting a baby for a misguided desire to have unconditional love, or a more prosaic desire to “trap” her partner.

    Too many 16yos have been brought up on sitcoms, rom-coms, and daydreams during which pregnancy at that age consists of cute little outfits, a body that doesn’t change at all except the temporary addition of an adorable “baby bump” and that “glow” (usually enhanced with camera work), maybe some juvenile humor about morning sickness, a handsome, loving partner and loving family who “step up,” and relatively easy births that don’t disrupt life much, except to leave the now-mom with a beautiful baby that she adores and no one else can resist (although there may also be some juvenile diaper humor thrown in).

    What they don’t think much about are the expenses of getting maternity clothes, baby clothes, and baby supplies, which aren’t cheap and in the latter two cases have to be replaced or replenished frequently. They don’t think about the potential physical changes and problems that could arise from a pregnancy, ranging from the relatively mundane like a metabolic change that makes it easy to gain weight, to more potentially serious things like gestational diabetes. They don’t think about the pain of childbirth, which we’ve all heard about, and husbands and fathers hear about ad nauseum if they dare say they feel the least bit unwell. They don’t consider that their families might be less than thrilled at the addition of a baby without consultation or notice, who’s going to change ALL of their lives, and not necessarily for the better, or that their (often just as young) partners might decide this daddy thing isn’t working out, so it’s time to make themselves scarce. They definitely don’t think about the grind of sleepless nights, uncomfortable feedings, aching eardrums from the constant screeching, endless stinky diapers, and all the day-to-day things mothering an infant requires and whether they have the stamina for it.

    Adopting the attitude of “it’s my job to provide whatever care the patient asks for, keep it quiet, and not say a word otherwise,” could just as easily be malfeasance as fulfilling any obligation. Her duty is to be the patient’s caregiver, not her enabler, and definitely NOT to perform her duties as if they were happening in a bubble, with no real-world consequences.

  7. “Counsel the girl, but refuse to help her get pregnant.”

    “Tell the girl, “Come see me when you’re 18, have a diploma, a job and are married.””

    At this point in the young girl’s life, what’s the difference between these two responses other than level of detail in the “counselling” statement?

  8. In my opinion, the job title the person is irrelevant. This sixteen-year-old is a child. The practitioner is an adult. The adult should summon the courage and the bravery not to abdicate her responsibility we all have as adults to point children in the right direction. Let us not forget here we are also talking about a potential new human life that will suffer also. The consequences of the first child’s adolescent reasoning are far-reaching beyond what the child is able to comprehend. The last thing this world needs is another soon to be unwanted and hungry mouth to feed. Is it not incumbent upon adults to give children the right answers to their questions instead of kicking the can down the road for some else to deal with the aftermath? All we are talking here is the prevention of the first domino from falling to prevent a series of future disastrous events. It is up to the adult to at least attempt to guide this child in the right direction. Anything else is pure cowardice.

  9. Just a nitpick Jack: the age of consent is not universally 18. Each state has their own respective laws, and in quite a few it is 16. The federal laws only kick in for crossing state lines for such conduct or photography of those under 18.

    This is a great example of what is legal isn’t necessarily moral. There is still a lot of maturity growth in those years. 18 and 16, ok. 19 and 16 is iffy. 25 and 16 is nothing but exploitive.

    • Yeah, since those details were unknown, I used the 18 year-old assumption for discussion purposes, and should have explained that the girl’s age would be legal in more than half the states.Since Appiah writes for a New York publication, I assumed the nurse was in NY. In New York, the age of consent is 17.

  10. “But the social and economic consequences don’t fall within your professional competence.” -Appiah

    I was in a twitter conversation the other day about traditional building methods and a critique of modernism and post modernism came up. The general notion that modernism and post-modernism don’t really stand for any coherent “style” or set of design rules or values, but that the two philosophies on real motive is a rejection of any inherited value-sets, traditions or rule-sets. This rudderless and destination-less method of course leads to an ugly and useless art and architecture environment. But that’s a separate argument from the current discussion. One of the guys in the conversation mentioned that one of the key problems of modernism is a hyper-specialization. Now in this context, he was asserting that nobody having skill sets outside of their “profession” is a bad thing (I agree, I’m not sure how bad the problem is currently though). Outside of this particular context, I think it is applicable as well.

    I am not just a repository of skills related to my professional training, nor am I limited by obligations that “only” my chosen profession can answer. Appiah’s comment here is dangerous and greases the road to the tyranny of “experts”. As a young lieutenant, in charge of a platoon of younger guys, I was NOT a trained financial advisor, but I certainly knew enough and *was in a position to do something about* those soldiers blowing their paychecks on items, such at $40,000 cars, that they had no business or need to purchase.

    We are humans inside a community BEFORE we are the professions we practice within that community. We are, therefore, obligated, to behave as WHOLE humans, not just an isolated bundle of information related to our particular cog in the whole machine. I don’t have to be a financial advisor, a spiritual counselor, an economist, or a family planner to know that having a child in the situation of this young woman would be devastatingly foolish. Nor does my lack of being any of those professions obligate me to keep my mouth shut on the issue. I’m an adult with a wide range of experiences, and if we aren’t sharpening each other as iron sharpens iron, then instead of choosing gradual growth and improvement as a community, we’ve chosen stagnation and degradation as a community.

    “So what if the advice seems “moralizing and intrusive” to the girl?” -Jack

    So yes, we are obligated to give each other our opinions of the choices our fellows make if we are in a position that has a reasonable chance to make a difference…even if it sounds moralizing and intrusive. Societies do not improve if corrections aren’t made. Corrections can come after painful consequences or they can come before a decision leading to painful consequences. I for one favor the latter option. While neither option guarantees the receiver of the correction will actually grow, relying on the accidental and fickle nature of consequences, even if the “learner” does learn from the mistakes, still saddles the individual with a plethora of other non-ethical considerations that they would be much better off not having to navigate.

    But not everyone has the power to make a difference or give advice. That only comes from someone who has authority to do so. Make no mistake, authority isn’t conferred solely by a professional degree. Authority is also built by demonstrating care for your fellows (especially care for the individual you are trying to influence) in addition to the life experiences or wisdom coupled with candor.

    Tangentially, Appiah’s advice is also the grounds for why during this pandemic, people who aren’t doctors are told to shut up about their opinions regarding the increasingly oppressive quarantining measures. Sorry, but that doesn’t fly. We all have enough knowledge to rightfully weigh in on this topic.

  11. I don’t think her reasoning shows she is ready for parenthood. A woman I knew did the same dropping school and having kids before able to support them and herself, and most of her kids repeated the same mistake. The youngest and her child had serious consequences because she was young. Bowing to whatever pressure or enticement making the girl think a baby will magically give her a happy ever after, is more likely to leave her trapped in the lower rungs of society. Encouraging children is not some pragmatic genetic decision that teen parenthood is better for her or child’s future. She has more years left to become a parent than she has yet lived.

    I would like to suggest her lover may also be underage so a LOT of the commentary about statutory rape here might not apply. If he also lives at home, they might believe his part-time job is plenty to live on. Young and stupid is not just for 16-year old girls.

  12. “We are told that the woman (?) 1) is 16, 2) is not attending school, 3) is unemployed, 4) is not married, and that her ‘partner’ has a ‘steady job,’ whatever that means.”

    What weren’t we told about this 16 year-old woman? Anything about her parents.

    After going through the article & comments twice, and conceding it may have been overlooked, the only reference to this gal’s parents was from Steve-O- (“16-17yo girls whose homes are broken or who want to run around on their parents), and that only as an oblique reference.

    This may be comparing apples to ’34 Packards (H/T Jack), but what if this gal were trying to secure a tattoo?

    Aspiring underage tattoo recipients need parental permission (in the good ol’ U. S. of A. leastways) to get inked, if they can get inked at all.

    “According to data through March 2015 compiled by the National Conference of State Legislatures, at least 45 states have laws prohibiting minors from getting tattoos, with the majority of those states allowing it if there’s parental consent. For example, Florida law requires written, notarized consent of a minor’s parent or legal guardian in order to tattoo a minor.” (bolds mine)

    Aspiring underage abortion recipients?

    ”According to Guttmacher Institute, a group that tracks abortion policy and statistics, a majority of states require consent and/or notification.

    In 38 states, minors either have to get consent and/or notify their parents, while in 12 states they don’t need either.” (bolds mine)

    Nationwide, it appears easier, or at least not as difficult, to get an abortion than it is to get a tattoo.

  13. I voted for “Tell the girl, ‘Come see me when you’re 18, have a diploma, a job and are married'” because their wasn’t a selection reading, “Grab the girl by the scruff of her neck, bash her head repeatedly against the table, all the while screaming, ‘You moron! You are too damn young to have a baby! How are you going to feed it? How are you going to cloth it? What about medical treatment? What about schools? Do you have any idea that you are about to embark on a road of poverty and you most assuredly will be punishing your child to an unnecessarily awful childhood? You want baby? Get a cat!'”

    That sounds harsh, no? Well, too bad. Life’s tough. Ask COVID-19.

    The Ethicist Appiah is forgetting what has been pointed out by Steve-O, mariedowd, our esteemed Ethics blogger, Michael, and Steve above, which is just because you may not be an “expert” you still have a duty to society to prevent harm that is within your realm of control. Tony’s comments from the medical perspective are interesting, but I did get the unstated message in his post pretty clearly: under-age motherhood is a monumentally awful idea.

    What is interesting is that nowhere in this discussion is there a consideration for the child this child wants to conceive and bring forth into the world. This girl’s desires are nice and sweet as so many stupid Disney and Rom-Com show say but the bigger concern (especially from Appiah’s perspective) is what damage this 16 year old girl will heap on an unsuspecting and innocent child.

    Additionally, I get that there are health care privacy concerns – HIPAA and other confidentiality regulations – but where in this discussion are the parents of this girl? I couldn’t read the whole thing on Appiah’s post because it is behind a paywall and I am not paying for the site. Are they around? Is the girl a ward of the court? Is she living in some group home for wayward girls? I suspect they are missing or completely incapable of being parents. Stupid is as stupid does.

    jvb

  14. Many years ago I worked in a Job Corp Center as a vocational counselor. It was a coed residential center that served high school dropouts age 16 to 21 with minimal useful vocational skills. There was supposed to be no sex occurring at the center and if caught in the act that was grounds for expulsion from the program. But these teens and young adults found a way to do the wild thing, and as a result at one point we had five pregnant girls to deal with. The girls were frequent under the illusion that their sex partner would marry them. Good luck with that!

  15. I’m with WAHJR. The facts and circumstances given lead me to conclude the child (I doubt there are sixteen-year-old women) is unable to well care for and raise another child. It is therefore unethical for the child to attempt pregnancy and birth. It is also unethical for persons to assist the child’s unethical behavior. The profession of the person assisting does not make the child’s behavior ethical. Neither nurses nor doctors (nor anyone else) should help the girl get pregnant. (However, as Rich in CT counsels, the nurse should follow through to ensure the infertility is not a product of a more serious health issue.)

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