The committee received the following [edited] query from an AACAP member: “Is it ethical for a child and adolescent psychiatrist to dispense condoms to a 13 or 14 year old without notifying the parents?”
This article is premised on the belief that questions posed to the AACAP Ethics Committee, and the committee’s responses, might be of interest to the organization’s membership. In that vein, a specific question is raised and discussed. You are urged to review the question but then momentarily stop reading, in order to first consider how you might respond.
The committee received the following [edited] query from an AACAP member: “Is it ethical for a child and adolescent psychiatrist to dispense condoms to a 13 or 14 year old without notifying the parents?” Please stop reading and think about the matter for a few minutes. The question was circulated to the members of the committee. Below, you will find a composite response, summarizing the perspectives of, and points raised by, the members.
In our attempts to respond to such questions, one must consider the potential benefit, harmfulness and utility of the physician’s behaviors. In addition, consideration of the doctor-patient and doctor-family relationship is crucial. Finally, the personal perspectives of the physician, conscious and otherwise, ideally undergo self-examination. All of these considerations are addressed below.
A primary concern — would the CAP’s behavior, in providing a 13 or 14 year old with condoms, be in the patient’s best interest? (Note that, in the question, the adolescent’s gender is not specified. Thus another question — might the CAP’s “countertransferential” responses and behaviors differ depending on the sex of the patient?) Most committee respondents opined that the encouragement of sexual behaviors suggested by condom provision would not be beneficial for the recipient, if only due to the young adolescent’s emotional immaturity, even if the adolescent were already engaging in intercourse. However, if we pursue such a conceptual framework for the young adolescent, we must ask if the same line of thought applies to the 17 year-old adolescent. As we do, we must bear in mind that the average age of first experience of intercourse in the United States is 16–17.
A second concern is that when treating adolescents, one is engaged in a relationship of trust with the parent(s) or guardian(s) and the adolescent. The goal of the CAP in this delicate dance is to acknowledge the child or adolescent as an emerging, autonomous individual, while simultaneously acknowledging the decision-making, administrative and need-to-know roles of the parents. Legal concerns aside, a CAP’s surreptitious provision of condoms (and the emotionally powerful sexual auras surrounding these items) could easily suggest the CAP’s assumption of a parental role, supplanting that of the patient’s guardians, and would appear to be a betrayal of their trust. As one member wrote: “If the parent is not notified . . . why do we bother to get consent for treatment?” It would certainly behoove the CAP to question him/herself as to the personal reasons, quite possibly unrelated to the patient, (s)he might consider engaging in this role, and the potential impact on the future of treatment provision when the parents/guardians learn of the CAP’s actions.
A third concern — is that it is important to consider the ostensible, as well as the hidden reasons, which may underlie the adolescent’s request. Most prominently, why does the patient choose to not discuss the matter with the guardian(s) or parent(s)? Is it disapproval, or even approval, that is feared? Or has the patient discussed the matter with the family and been rebuffed? Is the family context one of (an) abusive parent(s)? Is the adolescent intending to provide the condoms to a friend or partner, planning to masturbate, currently engaging in sexual activity, or simply anticipating doing so? Is the adolescent looking for support for the behavior from the CAP, or seeking discouragement of it? Is the proposed activity likely or not to lead to pregnancy or STD acquisition? Has the adolescent posed the question to others: peers, older or adult friends, as well as to the CAP or not? If not, why not? A member’s relevant comment: “Condoms are not prescription products . . . they are available over the counter.” To what extent is the adolescent testing the CAP for his or her response and looking for guidance, in contrast to the actual acquisition of the objects?
The predominant response of the committee is that to accede to the request would likely mean the adoption of an unethical stance. (Specifically, which feature of ethical principles is at work?) The opportunity for the exploration of the dynamics behind the request would likely be compromised, an (probably unnecessary) assumption of the parental role would have occurred, and behaviors that are generally thought to require greater maturity would be inadvertently encouraged. How much of this reasoning would continue to apply to the older adolescent, how CAPs might respond differently to requests from adolescents based on gender (both of the patient and the psychiatrist), what role, if any, religious considerations might play, and how the responses of CAPs residing in countries outside the United States might differ from those produced in a North American ethos are questions that would be interesting to address.
Note that the above discussion focused on ethical reasoning, not on forensic and or legal concerns. The aware CAP should, in addition to the considerations described above, be knowledgeable of state laws regarding degrees of autonomy and confidentiality provided to adolescents concerning their access to sexually related treatments, medications and paraphernalia. Also, clincians need to be aware of state laws which have codes militating against the early sexual activity of the very young. At the same time, “We should not have any gag order on talking with patients about sexuality, sex and contraception.”
Finally, it is also important to mention that a few members envisioned, once all the circumstances were fully understood, “ . . . that providing the condoms might (conceivably) be the most acceptable of several bad options.” Many shared the view that “whether or not (un)ethical, it [i.e. provision of condoms] would rarely be wise, whatever the age of the patient.” And one member summed up his comments with, “If you want to feed a man, you don’t give him a fish, you teach him to fish.”
This discussion, and its quotes, suggests the degree of thought, knowledge and varied inclinations that the AACAP Ethics Committee members bring to their work. This discourse could serve as a prototype for the appearance in the future, in the AACAP News, of discussions of other questions reviewed by the committee. Submissions of ethics queries by AACAP members are highly welcomed. Please forward yours to firstname.lastname@example.org.
Adrian Sondheimer, M.D., chairs the AACAP’s Ethics Committee. He practices child and adolescent psychiatry in New York, New York.