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Mmi Question - 12 Year Old Patient


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Give them. Better than not and having the child get pregnant unintentionally. Yes, its below the age of consent, 18, but would you really deny a 16yr old birth control because their parents said no? Realistically, I've never heard of anyone requiring their parents permission for birth control. It's not an abortion, it's not highly controlled substances or an experimental procedure. Children are often capable of making decisions, and if they were fully aware and mature enough to take them regularly, and were willing to have a conversation about safe sex and STDs with me, then they are likely mature enough.

Obviously encourage the kid to ask the parents, offer to be there and help them have the conversation in my office if that helps, but cost vs benefit I wouldn't want to send a child home and have them get pregnant, and have their entire life course altered.

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Definitely want to ask why this patient want's them in the first place (more reasons to take than sexual), do they fully understand what it does, how it works, are they even sexually active. Ask about their sexual activity, maybe they are being forced into it by an older person. Lots of questions to ask before any action is taken. Patient centred care ftw ;). This might even be a multi-visit thing, not just in this one visit.

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if a girl asks for birth control, you give her birth control. Don't assume it's for sex - many people are on b/c to control their periods.

 

There is not legal debate regarding her status as a minor. She's perfectly within her rights to ask for b/c (an issue of consent) and not wanting her doctor to inform her parents (an issue of confidentiality).

Regarding consent, healthcare laws specifically makes exceptions for minors when it comes to treatments for STIs, substance abuse, mental health and family planning (contraceptives and treatments related to pregnancy). 
There're also explicit laws allowing the doctor to maintain confidentiality from the parents when a minor patient when comes in for family planning purposes.
Good source to read about this consent and confidentiality of minors: https://www.law.uh.edu/hjhlp/Issues/Vol_82/McGuire.pdf

 

I would definitely ask what she wants it for - because I would ask the same of any patient requesting a medical treatment, but if she doesn't want to say then for the sake of maintaining trust, I would not push her.  If she does open up and it's because she wants to have sex, then it'd be a nice segway in to sexual safety and counselling.  

Since she wants to keep this a secret from her parents, I would also ask why, not because I think she should tell her parents, but because I want to know more about her relationship with them and whether there are problems at home.

Unless there's a medical reason for informing the parents - say she wants b/c because of painful and heavy periods from endometriosis, I would respect her request for confidentiality. I would also want to discuss what she thinks would happen if her parents happen to find out (while cleaning her room or something).  If she comes from a strict household, I'd be concerned about the possibility of violence. I'd also be concerned about losing trust with the parents if they were also my patients - but that's my problem to deal with, not hers.

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Definitely want to ask why this patient want's them in the first place (more reasons to take than sexual), do they fully understand what it does, how it works, are they even sexually active. Ask about their sexual activity, maybe they are being forced into it by an older person. Lots of questions to ask before any action is taken. Patient centred care ftw ;). This might even be a multi-visit thing, not just in this one visit.

 

I would agree here that consulting with the patient on the reason is the logically most important first step, the reason could be something like endo which can cause excruciating pain due to cramps. Although the thought process needs to go deeper than that. What would your response be given each possible answer. They are going to ask you probe questions remember, so try to think of a path for each possible answer she could give.

 

If it's for sex remember that the creed of medicine is to do no harm. Preventing pregnancy is great but the pill won't protect you from STIs. As a physician it is your duty to make this connection and ensure that you inform the patient of this and give them proper medical advice about safe sex.

 

If it is for endo then again you have a duty to inform the patient about their condition.

 

As well remember that there are many different types of pills that all have different hormones or combinations of hormones and that they might cause adverse reactions. Many times girls have to try multiple pills before they get one that works well for them without causing mood swings or causing them to have adverse physical reactions. So it is not a question of this MIGHT be a multiple visit thing, it will be, even if just to follow up and make sure that the current pill is working.

 

As well there are many ethical concerns here.

Is there a possibility of an abusive family, and that is why she doesn't want them to know, sure. Jumping to that conclusion though, in my opinion can show short-sightedness. It is important to ask about this possibility in a subtle and non-confrontational way, but most likely she is just a sexually active young girl who doesn't want her parents to know (the more likely scenario in my opinion).

There is also a possibility that she is in an inappropriate relationship, but as with the aforementioned parental issue, this is unlikely in my opinion.

I would address both of these as being in your thought process but don't make them the main point of your answer. You only have six to eight minutes and wasting it on trivial lines of thought is going to hurt you.

 

To me the major issue ethically here is on autonomy, and do no harm.

 

Is this girl at an age where she can make an INFORMED decision regarding her health care without the input of her parents? Could be argued either way <--- this should be the major part of your answer in my opinion.

If we give her the birth control what are the possible outcomes? Does this breach our duty to do no harm?

If we DON'T give her the birth control what are the possible outcomes? Does this present more harm than the latter possibility?

 

To me these last few questions make up the most important part of the answer.

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Case Study - Birth Control Pills

 

A 14 year old patient requests birth control pills from you and asks that you not tell her parents. What would you do?
 
This is a standard MMI-style question. We’ll go through it using the Doing Right algorithm.
 
1. What is the case?
A 14 year old patient requests birth control pills and asks for your discretion.
 
2. What are the ethical dilemmas?
The ethical issues involved are 1) autonomy vs. beneficence and 2) physican-patient confidentiality.
Special consideration must be applied as this case involves a minor making an autonomous decision.
 
3. What are the alternatives?
There are two choices that must be made here.
Give her the pills or Don’t give her the pills
and
Tell her parents or Don’t tell her parents
 
4. How do the principles apply?
Autonomy
Autonomy involves the patient’s (limited) right to choose their own course of therapy. If the patient is capable, defined as being able to understand and appreciate their situation, then their autonomy should be respected. This is true irregardless of the patient’s age. However, it is up to the physician to make sure the patient understands the risks and benefits involved in the autonomous choice. By giving her the pills, we are respecting her autonomy and building the therapeutic relationship.
 
Beneficence
Beneficence involves the physician’s duty to act on the best interests of the patient. In some cultures, giving her birth control pills could be seen as promoting a reckless sexual lifestyle that puts her at risk of acquiring STI’s or undue emotional turmoil. Because the patient is a minor, this can be seen as the beginnings of a slippery moral slope. On the other hand, physicians are not free to project their own beliefs or sense of morality onto their patients. It may be considered an ageist attitude to assume that the patient will engage in reckless sexual behavior. An argument can be made that she may just as well get the pills elsewhere, and it’s better if she gets them from someone who will be able to provide the proper counsel rather than risk the termination of the therapeutic relationship. Refusing to give her pills may also result in her engaging in sexual activity without them, which may lead to further complications.
 
Confidentiality
Physician-patient confidentiality is paramount to the therapeutic relationship. Breaking this trust can only be justified in cases where the patient puts others at risk. Circumstances that dictate this is outlined in Doing Right. In all other cases, confidentiality must be respected. If the parents were told, we break confidentiality, we risk the termination of the therapeutic relationship, we risk resentment in the patient of the medical profession, and we interfere with the patient’s family dynamics. If the physician is worried about the patient not getting proper counsel, he/she should refer the patient to a sexual health clinic or provide the care themselves.
 
5. What is the context? Who else is involved?
The context is not provided in the scenario, however, it is imperative that you address it. Cultural differences and perceptions about birth control and sexual health must be considered. In North America, a 14 year old girl having sex is drastically less scandalous than in conservative Asian countries. The relationship between the patient and her parents should also be explored, and counsel provided if necessary. 
 
6. Propose a resolution
The first thing to do is to listen to the patient and make sure she understands and appreciates the situation and what she is asking. It is important to counsel the patient on sexual health, or refer her to a sexual health clinic if she feels uncomfortable talking to you. In doing so, you address concerns of the patient’s increased risk for diseases, and you satisfy the rule of beneficence. I believe there is room for limited paternalism here, but only if you’ve earned the right to speak, to remind her that not everyone has her best interests at heart. I would give her the pills. There is no need to tell her parents.
 
7. Critical considerations
The practice of medicine differs widely between cultures. And while in certain cultures, this would be considered a taboo for physicians to give birth control pills to minors, in this culture, it is the patient’s right to have access to care. The prudent physician would make sure to follow-up on her, and provide further counseling, medical tests and care if necessary.
 
8. Action
 
Here’s an example answer:
 
“I think that this scenario raises numerous issues that are fundamental to the practice of medicine, such as patient autonomy and the physician’s duty towards beneficence. The ethical issue here addresses whether patients are free to choose a course of therapy that may results in adverse consequences or be frowned upon by cultural or societal factors. An additional facet of the scenario that the prudent physician must consider is that of physician-patient confidentiality.
 
For the issue of patient autonomy versus beneficence, I can definitely see both sides of the argument. On one hand, some may argue that by giving her the pills, I may be inadvertently promoting a lifestyle deemed unhealthy by certain societies or cultures and expose her to increased risks of sexually transmitted infections. Physicians are trained to provide health care and prevent diseases, and giving her the pills would appear to run counterintuitive to physicians. On the other hands, it may be considered and ageist attitude to assume reckless sexual activity and most of all, with the decline of medical paternalism, the patient’s autonomy in making decisions regarding her own care must be respected as long as the patient can understand and appreciate the risks involved.
 
In regards to confidentiality, while medical communications are not privileged, physicians have a duty to confidentiality except in cases of public harm. Breaking this confidentiality may result in lack of trust of the medical profession, and importantly, it may result in the termination of this therapeutic relationship.
 
In this specific scenario, I would first console the patient on sexual health, and the risks involved in being sexually active as well as guide her towards further resources if she requires help or feels uncomfortable talking to me further. In doing so I would have satisfied the rule of beneficence while also respecting patient autonomy. If the patient understands and appreciates the risks and benefits involved, I will give her the pills. There is room, I believe in this case of limited paternalism, where I may caution her to be careful and not all people have her best intentions at heart. There is no need to tell her parents if she demonstrates capacity to understand her situation and her request does not place herself in scenarios of serious harm to herself or others. Minors should be treated as autonomous beings.”
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