05 May 2015 Confidentiality, access to health care, and the debate on parental consent
The foremost considerations when debating the merits of a parental consent law are doctor-patient confidentiality and access to health care.
Confidentiality, first of all has proven to be of crucial importance in getting adolescents to use health care, particularly with regards to reproductive issues . This is obviously not, however, a fact unique to adolescents, though it is certainly portrayed that way. Interestingly, the Abortion Rights Coalition of Canada references an American privacy law (HIPAA) as an example of why confidentiality is crucial and parents should not be informed if their daughter chooses an abortion. That law, however, specifically mentions abortion in the context that an adolescent minor (under 18) may only maintain confidentiality in cases “when a minor has requested and received court approval to have an abortion without parental consent or notification” (emphasis added) . It is grouped with HIV/AIDS and sexually transmitted infections in that patient confidentiality may be maintained following court consent, but treatment or action cannot occur without adult consent. Further, confidentiality is not broken in that parents are told in secret. Adolescents are made aware of the requirement and informed of the need for parental consent before contact is made, and given the knowledge that they have the opportunity to seek court consent instead if necessary.
Access to health care, then, is the other major consideration. Such access can actually be improved by a parental consent law. It can be very difficult for adolescents to navigate the health care system on their own, from making appointments to transportation to appointments to accessing the follow-up care they may need. Absences from school or home will need to be explained, and the stress of dealing with pregnancy alone is obviously significant for an adolescent. Studies show that adolescents often know later in their pregnancy that they have conceived, or at least do not seek medical attention until they are “beyond facilities’ gestational age limits”.  While Canada has no laws restricting abortion, most doctors will only perform abortions before the 20 week mark, as after this point the fetus is considered viable. If the adolescent does present early enough for a drug-induced medical abortion, the complication and failure rates are higher than for surgically-induced abortion, so parental involvement and care can be very valuable .
An adolescent who gets an abortion in secret is more likely to hide her pain and complications following the procedure, putting her health at risk, and parents will not know to watch for signs of physical or psychological struggling. Studies have found a significantly higher rate (3-6x) of suicide in 15-24 year olds following induced abortions when compared to those who are not pregnant or who chose childbirth when pregnant, as well as decreased self-esteem and feelings of guilt, fear and confusion over what occurred [4-7]. A review of the literature from 1995-2011 found that pregnancy loss, including through abortion, carries a higher risk of subsequent mental disorder than childbirth. Thirteen studies showed a clearly higher risk for the abortion group versus those who chose childbirth, while only 5 studies found no difference .
The Canadian Medical Association, in its official policy on induced abortion, stresses the need for full and immediate counselling services for patients in the case of an unwanted pregnancy. This is much easier to ensure and maintain with parental consent requirements in place . Helping or encouraging adolescents to keep their pregnancies and abortions secret is helping them isolate themselves at a particularly vulnerable time, at an age where their coping mechanisms are not yet well-developed. That doesn’t sound like a consideration of best interests at all.
We must briefly consider the concern that is sure to be raised in dramatic fashion almost immediately. Is there the possibility that parental consent requirements will drive some adolescents to self-harm or illegal means of obtaining abortions in an effort to avoid telling their parents, or the now-infamous “coat hanger argument”? This common rhetoric has always held true for a small, sensationalized minority of cases, and will continue to do so. Desperate young women, like desperate older women, will take desperate measures. This does not, however, negate the need for a parental consent law with all its potential benefits for the majority. Rather than abandon parental consent, we should instead focus on alternate front-line support for these women who feel their situation is so dire they cannot possibly share the news of a pregnancy with a parent or guardian.
In terms of decision-making and consent, the terms mature or immature are not meant as a comment on an adolescents’ character or intellect, but rather as a scientific reality in terms of brain development. Not only are adolescents likely to make their pregnancy-related decisions in a state of stress, emotion, and exhaustion, they are also doing so with a less-developed prefrontal cortex than an adult, one of the “key ways the brain doesn’t look like that of an adult until the early 20s” . Adolescent brains show marked differences not in intellectual ability compared to adults, but in areas of impulse control and planning for the future. Those last-to-develop capacities are critical to making an informed decision on parenthood. These abilities are accessible in their parents, who can assist them in reasoning through a decision beyond the emotional basis, and beyond what peers are capable of.
In addition to the incomplete brain development of adolescents, there are marked hormonal shifts occurring in adolescence. These shifts affect the intensity with which emotion is felt as well as stress levels. Add to that the hormonal shifts that come with pregnancy and you have a dangerous decision-making cocktail which, like many cocktails, will lead to regretted decisions.
The argument put forward regarding adolescents needing consent to continue with a pregnancy should be dismissed without further consideration. Just as parental consent is needed for any surgery, so it should be needed for abortion at any stage of pregnancy – we do not ask for parental consent for an adolescent to get appendicitis or cancer, we simply involve them in helping their child cope with the consequences. As stated in R. v. Morgentaler, abortion is not a right, and should not be treated as such .
Parental consent does not equal parental control – it is about responsibility and care. Parents can share their reasoning and attempt to influence the decision, but the main goal is to provide support for pregnant adolescents regardless of the outcome of their pregnancy.
1 English, A. & Ford, C. (2004). The HIPAA privacy rule and adolescents: Legal questions and clinical challenges. Perspectives on Sexual & Reproductive Health, 36 (2)
2 Dobkin, L., Perucci A. & Dehlendorf, C. (2013). Pregnancy options counseling for adolescents: Overcoming barriers to care and preserving preference. Adolescent Pregnancy, 43 (4), 96-102.
3 Lanfranch, A., Gentles, I. & Ring-Cassidy, E. (2013). Complications: Abortion’s Impact on Women. The deVeber Institute for Bioethics and Social Research, ON, Canada.
4 Ely, G., Flaherty, C. & Cuddeback, G. (2010). The relationship between depression and other psychosocial problems in a sample of adolescent pregnancy termination patients. Child & Adolescent Social Work Journal, 27 (4) 269-282.
5 Gissler, M., Hemminki, E., Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987–94: register linkage study. BMJ 313: 1431.
6 Curley, M. & Johnston, C. (2013). The characteristics and severity of psychological distress after abortion among university students. Journal of Behavioral Services & Research, 40 (3), 279-293.
7 Humphrey, M., Colditz, P., Flenady, V. & Whelan, N. (2013) Maternal and Perinatal Mortality and Morbidity in Queensland Queensland Maternal and Perinatal Quality Council Report 2013. State of Queensland (Department of Health). Retrieved from http://www.health.qld.gov.au/caru/networks/docs/qmoqc-report-2013-full.pdf
8 Bellieni, C. & Buonocore, G. (2013). Abortion and subsequent mental health: Review of the literature. Psychiatry & Clinical Neurosciences, 67 (5), 301-310.
9 CMA Policy: Induced Abortion. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD88-06.pdf
10 The teen brain: Still under construction. http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml
11 Canadian Medical Association, Code of Ethics, 2004. https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf
12 R. v. Morgentaler (1988) 1 SCR 30, 1988 CanLII 90 (SCC). Retrieved from https://www.canlii.org/en/ca/scc/doc/1988/1988canlii90/1988canlii90.html?searchUrlHash=AAAAAQAZcGFyZW50YWwgY29uc2VudCBhYm9ydGlvbgAAAAAB&resultIndex=1