Adolescents, Legal and Ethical Issues
Adolescents have unique legal status with regard to the provision of health care. Legally they are accorded more rights than children, but in some matters they may have rights that differ from those of adults. These issues are addressed by state minor consent laws that may allow minors to give their own consent for health care. These laws differ by state. However, in all states, adolescents who are at least 14-years-old can be diagnosed and tested for STDs without parental consent or knowledge, and some states have specific provisions regarding testing for and treating HIV infection. Beyond STD diagnosis and treatment, there are some basic issues providers confront in dealing with adolescents:
1. Is the adolescent who is under 14 years of age old enough to have the authority to consent to care without parental involvement? Must the provider request any specific evidence of age?
2. Does the adolescent have the authority to release or prevent release of confidential information (particularly to parents?)
3. Is the adolescent or another source responsible for payment for services rendered. Can adolescents insist that parents not be contacted for health insurance coverage or payments?
In the US, the answers vary by state; however, some geralizations are possible. First, it should be noted that in most states the age of majority is 18, but in three states (Alabama, Nebraska, and Wyoming) it is 19, and elsewhere 21 (Mississippi, and District of Columbia). However, as stated, all states either have specific statues or otherwise permit the diagnosis and treatment of “venereal disease” (the usual terminology) without parental consent.
Although all states and the District of Columbia permit a minor to consent to STD care without parental consent, some states identify an age criterion. In five states (Alabama, California, Delaware, Illinois, and Vermot), minors must be at least 12 years old to consent to STD-related care, and in five states (Hawaii, Idaho, New Hampshire, North Dakota, and Washington) they must be 14-years-old. Laws may also address the extent to which providers can, in “good faith,” rely on information provided by the minor about his or her ability to consent. Over a dozen states have such a statement (Alabama, Alaska, Colorado, Delaware, District of Columbia, Indiana, Maine, Massachusetts, Minnesota, Missouri, Oklahoma, Pennsylvania and Texas).
In general, providers are obligated to maintain confidentiality, although communication with parents is sometimes addressed specifically. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) suggests statutory protection, by indicating that when minors consent to their own care without parental consent, parents do not necessarily have the right to information related to that care. However, it is state law that determines the specific protections that are applicable (i.e., medical, privacy laws, state minor consent laws, etc.) In several states, laws indicate that the information is confidental, and thus parents cannot be informed without the minor’s consent (e.g., California, Connecticut, Delaware, Florida, Hawaii, Iowa, Massachusetts,) although exceptions are made if life or limb are in danger (Massachusetts), or if the adolescent is found to have HIV (Delaware, Iowa). Other states either permit the provider to notify parents, indicate that providers are not obligated to notify parents, or do not address the issue.
Most states have not specifically addressed this issue. However, in several states (Connecticut, District of Columbia, Maine, Minnesota, and Oklahoma, and also in the Montana), depending upon ability to pay, the minor who seeks STD care is liable for costs. In many others it is stated that the parents are not liable, and therefore cost recovery would not be a reason to contact them.
The specific issue of a minor consenting for care relating to HIV/AIDS has been addressed by a majority of states. Many states have statues that permit emancipated minors in “special circumstances”- those who are married, are themselves parents of children, including diagnosis and treatment of HIV infection. In addition, many states have laws specifically authorizing minors to give consent for HIV testing. Furthermore, several other states indirectly authorize minors to consent to diagnosis and treatment of HIV infection by either (1) stating that HIV/AIDS is an STD and permitting minors to consent to diagnosis and treatments of such conditions. As a result, adolescents in well over half of the states can consent to diagnosis and treatment of HIV infection, although some laws may limit the care to testing.
Clinicians caring for adolescents should know the laws regarding medical treatment of minors in their locale. Some health-care workers may feel a conflict between the desire to honor a minor’s right to confidentiality and the desire to involve a parent or other adult. In addition to being aware of laws supporting an adolescent’s right to confidential care for STDs, providers should realize that by disclosing confidential information they may undermine the ability of any provider to care for adolescents in the future, particularly with regard to these sensitive issues.