One of the parenting truisms I have heard over the years is that there are two particularly challenging phases of childhood. The first is toddlerhood, and the second is adolescence. As the parent of a wonderful, charming, bright, inquisitive and often utterly infuriating almost three-year-old, I know the former has proved true in my experience. (He’s the greatest kid in the world, don’t get me wrong. Which is why he continues to survive such exploits as announcing his need to poop on the potty just as I was preparing my lunch and heading out the door for work yesterday morning.) For some reason, I have chosen to make the latter age group the subject of my professional subspecialization.
I mention all of this because I have genuine sympathy for harried, frustrated parents who are afraid their kids are on drugs. Though my son isn’t old enough to make me worried about this kind of misbehavior, I think I understand their perspective.
But I will not order drug tests on teenagers when the patients themselves withhold consent. (I have only ever made one exception to this, which I will discuss briefly later.) If there is concern about the teenager being acutely under the influence and at imminent risk to himself or others, then parents are advised to seek care in an emergency department, where the protocols and ethical obligations are different. But if there is no acute risk of harm, I don’t do the tests.
This is often the cause of great consternation and anger to parents. They still exercise legal authority over their children, after all, and they bring their children to me for care at their own discretion. Who am I to refuse their request? How dare I undermine their prerogatives so bluntly?
The first answer is strictly medical — if your question is “is my kid doing drugs?”, then a negative urine test won’t give you a definite answer. Urine clearance times vary widely [PDF] from drug to drug and with the frequency of use. If your teenager is using cocaine or methamphetamine sporadically, with the last ingestion several days ago, then her urine test could well be negative by the time you get her into my office. What’s the point of a test that cannot reliably answer the question at hand? If she’s lying to you, I cannot promise to uncover the truth.
The next answer deals with confidentiality, and the legal protections surrounding access to confidential care for adolescents. While the law varies from state to state, from what I gather all states offer at least some limited protections that allow for teenagers to access certain confidential health services, specifically with regard to treatment of sexually transmitted diseases. My Google skills have failed me once again, so I haven’t found a comprehensive list of which states have what protections for which services. General guidelines for adolescent confidentiality [sorry, another PDF] tend to focus more on reproductive issues. However, in states with a more expansive understanding of the “mature minor” doctrine, it is understood that drug testing and counseling fall into the same bucket.
This doctrine basically holds that teenagers who demonstrate a certain threshold maturity and understanding of the risks and benefits of their own care have limited capacity to consent for it. Conversely, they have some limited capacity to withhold consent if they feel it is not in their best interests to grant it. The one time I have explicitly overridden a teenager’s refusal to consent for a drug test is when I had a clear sense that he didn’t have sufficient maturity to grasp the implications of his situation, and it was really in his best interests to honor his mother’s wishes. (I am still not sure if I made the right call in that case.) If you live in a more conservative part of the country or have a provider who doesn’t focus on adolescents to a large degree and thus has a less sympathetic view of their autonomy, you may get a different answer.
But the last reason I don’t order drug tests against my patients’ wishes is that it conflicts with the physician-patient relationship. Adolescents are a unique population, one whose interests are not always congruent with those of their parents, who are nonetheless charged with safeguarding it. An adolescent’s interest in having certain behaviors kept secret conflicts with a parent’s desire to know what their child is up to. Insofar as I don’t want my patients to be engaging in risky behaviors, my goals as a medical provider broadly align with most parents’ wishes. But my ability to act as a resource for my patients relies upon their assurance of confidentiality and protection from punishment.
If a patient perceives me primarily as an agent of his parents, then they have no reason to believe that they can disclose sensitive information to me and keep it protected. I cannot realistically expect him to be anything close to honest with me (an assumption I am already hesitant to make in the best of circumstances) if I am obviously willing to act on his parents’ behalf to extract through lab testing information he wishes to keep secret. My obligations as a physician prevent me from complying with parents’ wishes in this regard, no matter how well-intentioned I believe them to be.
If a patient refuses, I do my best to explain why it may be in her long-term best interests to reconsider. A refused test is almost certainly going to be perceived as positive. Agreeing to a test, even with the expectation that it may be positive, may be the first step in rebuilding trust and mitigating some of the consequences that might follow bad decisions. But if I can’t change her mind and cannot honestly say she is in imminent harm, then I respect her right to refuse.
Heaven knows, there have already been plenty of times when my advice as a pediatrician has been hard to follow as a parent. (It is hard to be blithely indifferent to your child’s refusal to eat, and I’ve maybe gotten into an unproductive food battle or two.) I hope I always have the kind of relationship with my son where I don’t have to consider ignoring his wishes and seeking a drug test. But if I ever did end up asking for one, I hope I’d understand why his own medical provider would refuse.