Specific laws determining an adolescent’s right to confidentiality in medical situations vary by state, and it’s important physicians be aware of the regulations specific to their region of practice. Each state has provisions allowing adolescents to legally consent to medical care in certain situations, including emergencies, pregnancy-related care, STDs and HIV infection, contraceptive care, substance abuse and mental health care.1 However, a right to consent does not guarantee confidential or accessible care.
In this case, the patient’s health insurance is provided by her parents. If she uses the insurance to pay for contraception, the billing process would likely generate an explanation of benefits report, which would be mailed to her parents, thus disclosing sensitive information.2
Title X (& Its Limitations)
In the U.S., many young people can independently access reasonably priced contraceptive care. The Title X publicly funded family planning program was enacted in 1970 with broad bipartisan support and signed into law by President Richard Nixon. Title X provides federal funds for family planning clinics, which are required to provide care regardless of patients’ ability to pay. For individuals with incomes above the poverty level, fees for service are based on a sliding scale.3
Title X clinics are present in every state. However, the accessibility of these clinics is variable and may be more limited in areas with widely dispersed populations due to transportation barriers.4
Rheumatologists who frequently prescribe teratogenic medications should acquire familiarity with family planning laws and resources in their region. Confidential, low-cost contraceptive services broadly enable all physicians to provide necessary medical care and are particularly essential for vulnerable populations, including adolescents. In the case above, if confidential family planning services are inaccessible to the patient, the physician will be unable to provide care without contradicting at least one of the central principles of medical ethics: autonomy, beneficence, non-maleficence and justice.
Challenging Choices
In the absence of accessible contraceptive care for the patient in the case above, the rheumatologist might consider changing her immune suppressant from mycophenolate mofetil to azathioprine, which poses less risk during pregnancy.5 Although this approach reduces the risk of teratogenic effects (should the patient unexpectedly become pregnant), beneficence is compromised because the physician would not ordinarily consider changing medications when the patient’s current treatment is highly effective. Moreover, to avoid violating confidentiality, the rheumatologist might be in the awkward position of providing the patient’s parents a false, or at least disingenuous, rationale for the change in medication.
