I recently wrote a blog entry about new guidelines for managing abnormal Pap smears in young women.
At the end of the ACOG Committee Opinion, there’s an interesting aside that deserves comment: the fine line about confidentiality issues and informed consent when evaluating and treating adolescents with these problems.
This is an issue that has come up more than once in our practice. Frequently, young women have Paps done as part of STD screening, or in order to get prescriptions for birth control pills. When their Paps occasionally come back abnormal, they’re called in for further work-up and possible treatment.
Historically, adolescents are allowed by state laws to obtain contraception and STD screening without parental consent. But, when a problem is uncovered, and further testing and treatment are necessary, the ethical and consent issues become cloudy.
For example, we recently had a 17-year-old woman with an abnormal Pap smear. When she came back for colposcopy, she insisted that the workup be kept confidential or she would not undergo the evaluation. We went ahead and did the evaluation without parental notification or consent under the assumption that we were managing STD. But, when a high-grade lesion that required excisional biopsy was uncovered, some of us questioned the wisdom of proceeding with the procedure without parental involvement.
This was a tough case. The patient clearly did not want her parents to know anything about this. But, we were recommending therapy with potential cervix-damaging consequences, and one could argue that a 17-year-old shouldn’t be responsible for such decisions on her own. And there were insurance issues here as well: her insurance coverage was as a minor under her parents’ policy, and we couldn’t guarantee that billing confidentiality could be maintained. She again threatened to avoid further care for her problem if that involved notifying her parents. So, we were faced with several ethical dilemmas…
As a patient advocate, I can make the argument that this condition is the result of STD exposure and that the patient should have the right to make adult decisions about adult problems. But as a parent, I would expect to be notified if my minor child needed a surgical procedure, especially if it had such far-reaching consequences as potentially threatening her fertility, or my pocketbook!
The obvious superficial best choice here would be for the adolescent to come out about this to her parents and receive their support, despite the consequences. But, that’s not always easy in all circumstances. And, it’s surely not easy being caught in these situations where we’re trying to provide the best overall support for our patients.