Currently, Canadian teens can access abortion without parental notification or consent. This lack of parental involvement disrespects the family relationship and leaves teens vulnerable to abuse, peer pressure, lack of follow-up care, and lack of support. While there are certainly concerns to be considered when implementing parental involvement requirements for abortion, these concerns do not outweigh the need for a law.
These concerns, including patient confidentiality, access to healthcare, and the possibility of abuse or broken family relationships, are serious issues that need to be considered.
So let us consider them, and see how all can be adequately addressed within the framework of legislation mandating parental involvement in a minor’s abortion.
Doctor-Patient Confidentiality
Confidentiality, first of all, has proven to be of crucial importance in getting adolescents to use health care, particularly with regards to reproductive issues [1]. We take this argument very seriously, and maintain the importance of confidentiality. Confidentiality is not broken, however, by a well-designed parental consent law: parents are not notified without the adolescent’s awareness. The adolescent is made aware of the need for consent, and given the option of obtaining judicial consent (from a court) instead of parental consent. This gives the option to circumvent parental involvement in cases of abuse, lack of a legal guardian, or other legitimate concerns. The safety and well-being of the adolescent is at the forefront, alongside the safety and protection of pre-born children. The majority of teens will benefit from the involvement of their parents in this major decision. A parental consent law is a step forward in protecting teens against coercion, peer pressure, abuse, future uncertainty, and other potential reasons they may choose abortion.
While confidentiality is a priority for patients, it is also important to point out that it is not an absolute right. In cases where others could be affected by our choice (in this case a pre-born child), there is precedent for setting limits on confidentiality. For example, counsellors need to report child abuse if it is reported to them, and lawyers are required to report a client’s plan to commit a specific crime. This is an example of an appropriate balance between protection of privacy, but also the rights of others, including parents, society, and pre-born children.
Access to Health Care
Access to health care is another consideration when it comes to minors seeking an abortion. 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 significant.
Studies show that adolescents often know later in their pregnancy that they have conceived, or do not seek medical attention until they are “beyond facilities’ gestational age limits”. [2] While Canada has no laws restricting abortion, most facilities will only perform abortions before the 20-week mark. 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 are very valuable [3].
An adolescent who gets an abortion in secret is more likely to hide pain and complications following the procedure, putting her health at risk, and her parents will not know to watch for signs of physical or psychological struggling. This can have dramatic consequences. Studies have found a significantly higher rate of suicide in 15-24 year olds following induced abortions, compared to those who are not pregnant or who chose childbirth. Post-abortive teens also indicated 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 [8]. It is evident, then, that a teenager should not be expected to face this decision and/or procedure alone, with all the potential ramifications.
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, something easier to ensure and maintain with parental consent requirements in place [9]. 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” [10]. Adolescent brains show marked differences in areas of impulse control and planning for the future, both critical to making an informed decision on parenthood, and capacities that are similarly unavailable in the peers they may turn to for help and advice.
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.
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.
The Canadian Medical Association Code of Ethics states that physicians must “balance the developing competency of minors and the role of families in medical decision-making”[11]. It recognizes that, while minors should be heard and their participation in their healthcare encouraged, minors cannot always make medical decisions unassisted. Abortion is also unique in that another life is involved besides that of the patient, deepening the impact of the decision.
Parental consent does not equal parental control – it is about responsibility and care. It is still necessary to obtain the pregnant woman’s consent, meaning that the decision belongs to the adolescent. Her parents can share their reasoning and attempt to influence her decision, but the main goal is to provide support for pregnant adolescents regardless of the outcome of their pregnancy. The parents’ duty is to act in the best interests of their child. They cannot fulfill that duty if they are missing relevant information regarding the life and medical history of their teenage daughter. Whether the adolescent chooses abortion, adoption, or active motherhood, support is crucial to their success and well-being. A parental consent law makes it clear that the government supports young women as well as the lives they may carry, and is working to enhance their well-being now and across their lifespan.
Sources:
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.