Comment(s) Of The Day: “Ethics Quiz And Poll: The Nurse Practitioner’s Dilemma”

We have a rare two-headed Comment of the Day on “Ethics Quiz And Poll: The Nurse Practitioner’s Dilemma,”about the nurse practitioner’s dilemma when she was asked by a poor, unmarried, 16-year-old , unemployed high school drop-out to help her get pregnant. Taking a minority position among commenters (the post’s poll results overwhelmingly favored counseling the girl against pregnancy), commenter valkygrrl wrote,

“Assuming the local age of consent laws make the pairing lawful, I think we have our answer in regard to professional ethics:

(f) Not discriminate against patients who have difficult-to-treat conditions, whose infertility has multiple causes, or on the basis of race, socioeconomic status, or sexual orientation or gender identity.

Assuming the local age of consent laws make the pairing lawful, I think we have our answer in regard to professional ethics.”

Commenter Tony, a physician, added in his Comment of the Day #1,

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 counseling 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.

To this, John R. Billingsley added Comment of the Day #2:

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.

 

13 thoughts on “Comment(s) Of The Day: “Ethics Quiz And Poll: The Nurse Practitioner’s Dilemma”

  1. Since there’s a chance that I’m about to get slammed.

    It should go without saying that the best answer that crossed my path re: professional medical ethics should not be taken as approval for the 16-year-old’s life choices.

    • Val
      I will not slam anyone who offers a legitimate perspective based on factual data. Your comment of the day is well deserved.

      I do wonder what ethical obligation any person regardless of age has to society with respect to imposing on society the costs of rearing the child beyond providing an education. If none is owed to society what is owed to the conceived child who may go hungry or without adequate care because the mother was thinking only of herself at conception.

      While I understand the logic in the cited medical ethics, I don’t see within them the requirement to deliver services to the child at some reduced rate if the mother cannot afford medical care. It seems to me that if a persons professional ethics compels them to act one way then they should be obligated to incur some of the costs associated with those rules.

      • While I understand the logic in the cited medical ethics, I don’t see within them the requirement to deliver services to the child at some reduced rate if the mother cannot afford medical care. It seems to me that if a [person’s] professional ethics compels them to act one way then they should be obligated to incur some of the costs associated with those rules.

        Would you then send a bill to a defense attorney for the costs of any crimes commented by a client post-acquittal?

          • Actually upon reflection I dont think the lawyer analogy is appropriate. If a lawyer counsels a client how to commit a crime in advance that is closer to assisting a minor get pregnant. Nowhere would I have suggested that a minor who had given birth be denied services.

            A lawyer who helps facilitate a crime is as culpable as the one committing the crime. If that is the case then my question about shouldering the costs of helping a minor create a new person that will rely on societies public resources remains valid.

            If, through my acts, I create costs that will be borne by third parties, is that not a tortious act?

      • Irrespective of who the COTD belongs your comment was a reasonable perspective that was instructive to me.

        All the comments on this topic were valuable

      • if a persons professional ethics compels them to act one way then they should be obligated to incur some of the costs associated with those rules.

        That’s getting unnecessarily complicated. The medical professional is not acting unilaterally. Part of the questioning and counseling should and usually does, from the beginning, include encouraging the patient to take advantage of referrals to any and all other services available to the teen, some of which will be able to offer financial counseling and/or private help (some public assistance is there too, but would not be extensive until after the birth) . This is where Planned Parenthood shows its shining ethical side, by the way. And the need for funds might be one that leads to getting the parents involved.

        But if you’re suggesting that the doctor or nurse practitioner counseling the girl who is intent on becoming pregnant is in any way responsible in for the outcome of the pregnancy, no, I would not agree, however cold-blooded that may sound. Sad as it may be, that is the result of decision(s) the patient makes out of (hopefully) informed-as-possible consent. A physician with a private practice (hard to find these days) might be in a position to discount or waive fees but not if they share profits with a group or are contracted to a hospital. Many doctors will give time to work, pro bono, as it were, in free clinics, but there are whopping expenses for tests, hospital care and delivery besides. (Since 1994, when most hospitals in the United States were silently given over – taken over? – to “managed care” by private companies, the shareholders have uniformly frowned on cutting fees.)

        In the end – at the ideal ethical outcome – the mother (and possibly the putative father), as mature, well informed and supported as possible, will be responsible for the child.

        • Excellent points Penn. I asked the question to stimulate dialogue.

          The financial ramifications of primary care would place doctors in a no win situation.

          Then the question becomes should this minor, after being well informed continue on this course should society be obligated to pay for her decisions.?

  2. Both citations from the professional codes fall on the presumption that there exists “competent minors”. I would argue NO. I would also add the reality that there are fewer and fewer “competent adults, but that is another point. This young girl does not have the legal competence to sign contracts, She barely has the competence or the legal right to drive a vehicle, she cannot work under certain conditions, she can not enlist in the military, she cannot engage in any licensed professions, under most state laws she would be considered the victim of statutory rape if someone engaged in sexual activity with or without her consent.
    The professional codes cited above merely legally protect those who refuse to act with common sense.

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