Introduction

Adolescents raise difficult, and somewhat unique, ethical concerns. Unlike adults, who are primarily responsible for their own treatment decisions, parents and health professionals sometimes question the legitimacy of granting adolescents full responsibility for medical decision-making. Even in those cases where minors do have decisional capacity, their legal and financial status sometimes preclude health professionals from granting them full decisional authority.

Two ethical concerns arise in relation to adolescents' self-determination regarding their reproductive health: their ability to make their own treatment decisions (informed consent) and their ability to control access to their personal information (confidentiality). With very young children, there is no question that parents ought to be fully involved in medical decision-making and have access to their child's medical records. However, there is controversy regarding the extent of a health professional's obligation to respect adolescents' self-determination as they begin to mature, both physically and mentally.

Because of the special role that parents play in the child's development it is important to consider their input in most treatment decisions. Most parents provide their children with essential emotional and financial support. Such support may be necessary to meet the adolescent's medical needs. Health professionals do face a difficult challenge when minors wish to receive medical services without parental involvement. In these cases, health professionals should explore the reason why an adolescent wishes to keep information from a parent and encourage parental involvement when appropriate.

There is no magic age at which minors are endowed with decisional capacity and the corresponding ability to make informed treatment decisions. In general, minors should be included in the medical decision-making process to a degree commensurate with their decisional capacity. While many adults tend to discount the decisional capacity of minors, some studies suggest that by the time minors reach the age of fourteen or fifteen, many will have attained a degree of decisional capacity necessary to give their informed consent for many health care treatment decisions. A finding of decisional capacity gives some weight to a health care professional's obligation to respect their wishes.

Ultimately pediatric health professionals must recognize that their patient's decisional capacities will develop over time. By allowing even young minors to participate in treatment decisions, health professionals are fulfilling their obligation to their patient by facilitating the development of the minor's decisional capacity. As minors mature during adolescence, the health professional's obligation to respect the minor's treatment decisions increases.

In order to give their informed consent for reproductive health options, adolescents must be able to understand the risks associated with sexual activities and effective methods for minimizing those risks. Health professionals should be available to adolescents and provide accurate information regarding such options as abstinence, condoms, and other effective methods of birth control. Health professionals need to explore the minor's sexual activities and help the minor to make informed decisions.

In order to get adolescents to discuss the important issue or reproductive health, health professionals must often assure some degree of medical confidentiality. While confidentiality is essential to any patient/physician encounter, it is of extreme importance when dealing with reproductive issues for minors. Confidentiality allows for the development of a trusting relationship whereby patients feel comfortable disclosing personal and sensitive information that enables health professionals to provide appropriate medical treatment. As adolescents mature sexually, they are likely to develop legitimate health concerns that they wish to keep from their parents.

Some health professionals are comfortable providing confidential reproductive health care services to their adolescent patients. They feel that the need to protect the patient, and the patient's sexual partners, from sexually transmitted diseases and unwanted pregnancies justifies providing such care. Others are less comfortable and feel that parents have a right and need to fully participate in their minor's reproductive health care decisions. They are more willing to share information with the patient's parents.

In either circumstance, it is essential that health professionals establish boundaries for confidentiality early in the relationship. Health professionals must be careful not to mislead adolescents regarding the limits of confidentiality. Adolescents and their parents should be fully informed of the scope of the patient's confidentiality. This, however, can create a serious challenge. If health professionals decide to limit an adolescent's confidentiality, the adolescent may be less inclined to provide them with sensitive information, thereby increasing the reproductive health risks. By protecting the adolescent's confidentiality, health professionals may be accused of usurping the parents' right to participate in their children's reproductive health care decisions.