Asks Pierre Corneille:
I know you’ve discussed this somewhat in a recent post, but I’d like to hear more (if you’re willing) about how you balance your adolescent patients’ need for privacy and confidentiality with their parents’ “right” to know what’s going on with their child(ren).
For example, if you know that the children use drugs, when, if ever, do you tell the parents? Or if you know the children are sexually active and are being reckless or dangerous, do you ever break confidentiality. Or if those are too specific to what *you* do, what are the protocols as you understand them.
No worries, mate. I’m always happy to return to a familiar topic.
I almost never, ever violate confidentiality. It is among the tenets I consider most important to preserve in my practice, without which I cannot set my bearings.
Let’s start with your examples — if I know that an adolescent is using drugs, it is highly unlikely that I will disclose that to a parent. As I’ve written in the past, I won’t even order a drug test without a patient’s assent. If I were to speculate about what circumstances would need to pertain in order for me to disclose drug use, there would have to be a significant degree of exploitation, naiveté and youth before I would violate confidentiality. If a fifth grader were using drugs pushed by an older adolescent or adult lurking around their schoolyard, I would disclose that. But if someone is voluntarily using drugs for their own pleasure, I wouldn’t disclose it.
Similarly, if an adolescent is sexually active, I will not disclose it, even if the patient is engaging in sexual activity that I would consider high-risk. If the patient has been sexually assaulted, I understand the law to mandate that I report it. But if the sexual activity is voluntary, I won’t tell. Were I to have serious questions about the patient’s capacity to consent to sexual activity, I might consider disclosure if there were a significant concern about coercion or exploitation. That said, genuinely voluntary sexual activity stays private.
I don’t have so a protocol per se, but rather a benchmark. If a patient is an imminent threat to him/herself or someone else, then it gets disclosed. Patients are told when I start my spiel about confidentiality (which I give to all of my adolescent patients, at least when the topic is new to them) that if they tell me they are going to hurt or kill themselves or another person I have an obligation to disclose it. Homicidality or suicidality are disclosed without hesitation. If the patient or another person is in imminent danger, I cannot keep that information protected.
But if they’re not? Then my obligation is to the patient and his or her wishes. If they cannot be assured that their secrets are safe with me, whyever would they entrust them to me? If I am perceived as an agent of their parents or other authority figures and a threat to their autonomy, how can I expect that they will give me the information that I need to take care of them? I set bright lines around confidentiality because without them patients must guess at my intentions. They need to know that they are, in a sense, in a safe space.
Now, if I know a patient is using a pile of drugs or having sex with skeezey older guys, will I strongly, strongly encourage them to disclose it to someone else and seek help? You bet. I will try like hell to get them to tell some trusted adult, and to recognize the risks that they’re taking. I hate being the keeper of dark secrets, and will spend lots and lots of time with patients trying to help them see why they should consider telling someone else what’s going on with them. But if they refuse? Then they refuse.
Being a medical provider often involves being in uncomfortable positions. If you take care of real human beings, you are forced to confront their real human problems. Sometimes you have to stack one set of ideals against another. The decisions are sometimes not easy. But in my practice, the ideal of respecting patient confidentiality is nigh unto sacrosanct, and I preserve it under almost all circumstances.