Ethical Issues in Reproductive H ealth C are for Minors

1. Ethical Issues in Reproductive Health Care for Minors TheUniversity of Alabama Capstone College of Nursing Nursing 740 Valencia Hawthorne, Nicole Jackson, Heather Knutson, and Jenni Stracener

2. Introduction Confidential health services are important in the delivery of adolescent health care Health care providers are key to promoting adolescent reproductive health Concept of confidentiality can be complicated when factoring in: parents financial responsibility, parents’ theological beliefs in raising their child, and individual state laws regarding adolescent care (Loxterman, 1997) There are many factors that influence contraception regulation: culture, community, religion, politics, and economics (FIGO, 2012) Health care providers must understand state/local laws on confidentiality and those that obligate parental notification (American College of Obstetricians and Gynecologist, 2009)

3. Case Study A 16 year-old African American female presents to a primary care family practice clinic in Tennessee Patient is from Indiana, visiting her grandmother, who has notarized paperwork allowing her to sign for patient’s medical care Patient insists on seeing the Nurse Practitioner (NP) alone. The grandmother agrees, but requests that no oral contraceptives (OCPs) be given to her granddaughter per mother’s request During the exam, the patient specifically asks for OCPs not only to regulate her periods, but also because she admits she is sexually active The NP provides patient with 3 months of OCP samples and discusses sexually transmitted infections (STIs) testing and further contraceptive services once she returns to Indiana

4. After returning home, the mother finds the adolescent’s OCPs in her purse Mother is irate and calls grandmother who then contacts the prescribing NP NP then informs the grandmother of the confidentiality laws in Tennessee, which allows providers to give minors contraceptive services without parental consent This case delves into ethical and political decisions health care providers face when treating adolescents Most states allow confidential contraceptive treatment to minors, although many parents disagree This case study explores ethical and political issues related to prescribing contraception to minors without parental consent

5. Ethical Analysis • In 1997, U.S. Supreme Court ruled that minors have a right to privacy in regards to the use of contraceptives (Loxterman, 1997) • Confidentiality issues for minors are not covered comprehensively through federal statutes, but vary state by state with most states deciding that protecting an adolescent’s confidentiality is more important than parental notification (Loxterman, 1997) • Attempts in 1982 and again in the 1990’s to enact laws requiring parental notification of contraceptive services failed (Dallard & Richardson, 2005) • As of September 2008, all states allow minors to consent to testing and treatment services for STIs(ACOG, 2009) but laws still vary among states with regard to contraception • Eighteen states allow providers to contact a minor’s parents if the physician thinks it is in the minor’s best interests (Goodwin et al., 2012)

6. Ethical Analysis (Continued) When surveyed, less than twenty percent of adolescents would seek health care related to reproductive health if parental consent was required (ACOG, 2009) The federal Medicaid statute and the federal Title X Family Planning Program require access to confidential reproductive health services to program-eligible adolescents (ACOG, 2009) Professional health care organizations are crucial voices in ensuring the availability of contraceptive services to all women (FIGO, 2012) The American Medical Association, The American Academy of Pediatrics, The American College of Physicians, The American Public Health Association, The American College of Obstetrics and Gynecologists, and The American Academy of Family Physicians and Society for Adolescent Medicine all support the delivery of confidential health services for adolescents (ACOG, 2005; Loxterman, 1997)

7. Ethical Analysis (Continued) A 1999 study showed that 83% of pediatricians, 85% of family medicine doctors and 63% of internal medicine doctors would provide contraception without parental consent  (Lawrence, Rasinksi, Yoon, & Curlin, 2011) Federal and state sex family planning policies should be designed: “to reduce sexual activity among teens, to provide education and tools for safe sex, and to prevent unintended pregnancy and sexually transmitted diseases” (Yang & Gaydos, 2010) Policies should be evidenced based from empirical studies and should be periodically evaluated to prevent policies anchored in politics rather than in medicine (Miller, Cox, & Saewyc, 2010; Brindis, 2002)

8. State Laws States that allow minors to consent to contraceptive services: Alaska, Arizona, Arkansas, California, Colorado, Dist. Of Columbia, Georgia, Idaho, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, Montana, New Mexico, New York, North Carolina, Oregon, Tennessee, Virginia, Washington, Wyoming States without any explicit policy: North Dakota, Ohio, Rhode Island, Wisconsin States that allow “certain” minors to consent: Alabama, Connecticut, Delaware, Florida, Hawaii, Illinois, Indiana, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Hampshire, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Vermont, West Virginia (Guttmacher Institute, 2013)

9. Pros to Allowing Confidentiality with Minors • Teens often make immature decisions and “growing up” is learning how to weigh all consequences and make good decisions. Unfortunately, many teens do not live in supportive or loving families that could help them make good decisions (Goodwin et al., 2012; Lawrence, Rasinksi, Yoon, & Curlin, 2011) • Teen pregnancy in the United States cost taxpayers about $11 billion in one year (Goodwin et al., 2012) • 40% of kids have never discussed sex with their parents (Goodwin et al., 2012) • Required notification would dissuade minors from obtaining services (Lawrence, Rasinksi, Yoon, & Curlin, 2011) • Adolescence is a time for experimentation with adult behaviors, some of which could have long term implications (Muyle, Park, Nelson, Adams, Irwin, & Brindis, 2009)

10. Cons to Allowing Confidentiality with Minors • Parents have an interest in their child’s life (Lawrence, Rasinksi, Yoon, & Curlin, 2011) • Parental rights (Goodwin et al., 2012) • Various religious beliefs (Lawrence, Rasinksi, Yoon, & Curlin, 2011) • Different cultural beliefs (Yang & Gaydos, 2010)

11. DirectionIn practice As APRNs, we can improve patient care through the utilization of nursing paradigms and nursing theory to deliver optimal care Caring for the adolescent patients, specifically in reproductive health, there continues to be much controversy despite federal and state rulings of patient confidentiality Providers meet controversy trying to meet the holistic needs of patients, while giving them the respect of privacy and health management The delivery of healthcare to minors presents an opportunity to cultivate positive patient-provider relationships. This relationship leans largely on the ability of the advanced practice nurse to engage with the adolescent providing a trusting patient-focused environment Use of multidisciplinary teams such as psychiatrist, clergy and social workers to implement patient outcomes should be data driven and used in evidenced based practices Practitioners must be knowledgeable of the psychosocial and behavioral aspects of adolescent thought process to determine the best plan of care allowing for patient autonomy, while providing seamless confidentially driven healthcare

12. DirectionIn Research • More research and knowledge is required • Barriers to healthcare as identified in the Affordable Care Act must be investigated further • More research needs to be conducted on reproductive health concerns in the adolescent population • Well-designed studies are needed to gain more understanding of the reproductive health needs of the adolescent patient • Failure to fully investigate adolescent reproductive healthcare outcomes can lead to inadequacies in healthcare delivery • Inefficient reproductive healthcare can evolve into lifelong diseases and medical conditions • Investigational research will help determine best practices for minor aged patients • Evidenced based research equips multi-disciplinary teams to establish patient care models to meet the needs of adolescent patients and improve outcomes

13. DirectionIn Education • There is need for improved education with regards to adolescent reproductive health for minors • Moral and ethical consideration of adolescent reproductive health is significant and must be incorporated in implementation of patient and family education • Education in community and private sectors is paramount and should include reproductive health forums to include topics such as: • Health and contraceptive education • Obstetric care • Long-term effects associated with teenage pregnancy

14. DirectionIn Health Policy The fundamentals of nursing practice have been research and theory driven for decades Nursing hypothesis and theoretical frameworks are used to mandate changes in nursing practice Healthcare models become change agents Federal and state health policies help but do not completely alleviate the strain in caring for the adolescent patient We must incorporate current federal and state healthcare policies involving adolescent reproductive health in to practice We should also engage with lobbyist As patient advocates, we must keep the patient’s best interest as priority to allow for positive outcomes

15. Conclusion To promote adolescent health, providers need to cultivate confidential programs that incorporate the needs of adolescents (Loxterman, 1997) Adolescents will seek necessary medical care when confidentiality is ensured (Dallard & Richardson, 2005) Legislation at the state and federal level continues to confront the idea of providing confidential reproductive health services to adolescents (Dallard & Richardson, 2005)

16. Conclusion (Continued) A provider must “consider the patient's chronological age, cognitive and psychosocial development, other health-related behaviors and prior family communication” before confidentiality is promised (Lawrence, Rasinksi, Yoon, & Curlin, 2011, p 263) Future policy and interventions should focus on promoting access to contraceptive use. Contraception policies should keep in mind the needs of adolescents from different cultural backgrounds (Yang & Gaydos, 2010) New policies should support “evidence-based approaches to teen prevention”(Santelli, 2010, p. 516)

17. References ACOG. (2009). Confidentiality in Adolescent Health Care. Retrieved from http:// www.acog.org/~/media/Departments/Adolescent%20Health%20Care/Teen%20Care%20Tool%20Kit/ACOGConfidentiality.pdf?dmc=1&ts=20131104T21344368 01 Brindis, C. D. (2002). Adolescents, Health Policy, and the American Political Process. Journal of Adolescent Health, 30(1), 9-16. Dillard, C., & Richardson, C. T. (2005). Teenagers’ Access to Confidential Reproductive Health Services. The Guttmacher Report of Public Policy 8(4), 6-11. FIGO. (2012). Ethical Issues in Obstetrics and Gynocology. Retreived from http:// www.figo.org/files/figo-corp/English%20Ethical%20Issues%20in%20Obstetrics%20and%20Gynecology.pdf Fox, H. B., Mcmanus, M. A., & Limb, S. J. (2003) Early Assessments of SCHIP's Effect on Access to Care for Adolescents. Journal of Adolescent Health, 32(6), 40-52. Goodwin, K. D., Taylor, M. M., Brown, E. C., Winscott, M., Scanlon, M., Hodge, J. G., Mickey, T., & England, B. (2012). Protecting Adolescents’ Right to Seek Treatment for Sexually Transmitted Diseased without Parental Consent: The Arizona Experience with Senate Bill 1309. Public Health Reports, 127, 253-258. GuttmacherInstitute. (2013, Nov 1). [PDF Table] State Policies in Brief: Minor's access to Contraceptive Services. Retrieved from http://www.guttmacher.org/statecenter/ spibs/spib_MACS.pdf

18. Lawrence, R. E., Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2011). Adolescents, contraception and confidentiality: a national survey of obstetricians-gynecologists. Contraception, 84, 259-265. Loxterman, J. (1997). Adolescent Access to Confidential Health Services. Retrieved from http://www.advocatesforyouth.org/publications/publications-a-z/516-adolescentaccess-to-confidential-health-services Miller, B. B., Cox, D. N., & Saewyc, E. M. (2010). Age of Sexual Consent Law in Canada. The Canadian Journal of Human Sexuality, 19(3), 105-119. Muyle, T. P., Park, M. J., Nelson, C. D., Adams, S. H., Irwin, C. E., & Brindis, C. D. (2009). Trends in Adolescent and Young Adult Health in the United States. Journal of Adolescent Health, 45(10), 8-24.  Resnick, M. D., Bearinger, L. H., Sieving, R. E., & Eisenburg, M. (2003). Parental Perspectives on restriction Adolescents; Reproductive Health Options: a population- based survey of parents of teens. Journal of Adolescent Health, 32(2), 133.  Santelli, J. (2010).State Policy Effects on Teen Fertility and Evidence-Based Policies. Journal of Adolescent Health, 46, 515-516. Yang, Z. & Gaydos, L. M. (2010). Reasons for and Challenges of Recent Increases in Teen Birth Rates: A Study of Family Planning Service Policies and Demographic Changes at the State Level. Journal of Adolescent Health, 46, 517-524.