Case Study - Birth Control Pills

A 14 year old patient requests birth control pills from you and asks that you not tell her parents. What would you do?

This is a standard MMI-style question. We’ll go through it using the Doing Right algorithm.

1. What is the case?

A 14 year old patient requests birth control pills and asks for your discretion.

2. What are the ethical dilemmas?

The ethical issues involved are 1) autonomy vs. beneficence and 2) physican-patient confidentiality.

Special consideration must be applied as this case involves a minor making an autonomous decision.

3. What are the alternatives?

There are two choices that must be made here.

Give her the pills or Don’t give her the pills

and

Tell her parents or Don’t tell her parents

4. How do the principles apply?

Autonomy

Autonomy involves the patient’s (limited) right to choose their own course of therapy. If the patient is capable, defined as being able to understand and appreciate their situation, then their autonomy should be respected. This is true irregardless of the patient’s age. However, it is up to the physician to make sure the patient understands the risks and benefits involved in the autonomous choice. By giving her the pills, we are respecting her autonomy and building the therapeutic relationship.

Beneficence

Beneficence involves the physician’s duty to act on the best interests of the patient. In some cultures, giving her birth control pills could be seen as promoting a reckless sexual lifestyle that puts her at risk of acquiring STI’s or undue emotional turmoil. Because the patient is a minor, this can be seen as the beginnings of a slippery moral slope. On the other hand, physicians are not free to project their own beliefs or sense of morality onto their patients. It may be considered an ageist attitude to assume that the patient will engage in reckless sexual behavior. An argument can be made that she may just as well get the pills elsewhere, and it’s better if she gets them from someone who will be able to provide the proper counsel rather than risk the termination of the therapeutic relationship. Refusing to give her pills may also result in her engaging in sexual activity without them, which may lead to further complications.

Confidentiality

Physician-patient confidentiality is paramount to the therapeutic relationship. Breaking this trust can only be justified in cases where the patient puts others at risk. Circumstances that dictate this is outlined in Doing Right. In all other cases, confidentiality must be respected. If the parents were told, we break confidentiality, we risk the termination of the therapeutic relationship, we risk resentment in the patient of the medical profession, and we interfere with the patient’s family dynamics. If the physician is worried about the patient not getting proper counsel, he/she should refer the patient to a sexual health clinic or provide the care themselves.

5. What is the context? Who else is involved?

The context is not provided in the scenario, however, it is imperative that you address it. Cultural differences and perceptions about birth control and sexual health must be considered. In North America, a 14 year old girl having sex is drastically less scandalous than in conservative Asian countries. The relationship between the patient and her parents should also be explored, and counsel provided if necessary. 

6. Propose a resolution

The first thing to do is to listen to the patient and make sure she understands and appreciates the situation and what she is asking. It is important to counsel the patient on sexual health, or refer her to a sexual health clinic if she feels uncomfortable talking to you. In doing so, you address concerns of the patient’s increased risk for diseases, and you satisfy the rule of beneficence. I believe there is room for limited paternalism here, but only if you’ve earned the right to speak, to remind her that not everyone has her best interests at heart. I would give her the pills. There is no need to tell her parents.

7. Critical considerations

The practice of medicine differs widely between cultures. And while in certain cultures, this would be considered a taboo for physicians to give birth control pills to minors, in this culture, it is the patient’s right to have access to care. The prudent physician would make sure to follow-up on her, and provide further counseling, medical tests and care if necessary.

8. Action

Here’s an example answer:

“I think that this scenario raises numerous issues that are fundamental to the practice of medicine, such as patient autonomy and the physician’s duty towards beneficence. The ethical issue here addresses whether patients are free to choose a course of therapy that may results in adverse consequences or be frowned upon by cultural or societal factors. An additional facet of the scenario that the prudent physician must consider is that of physician-patient confidentiality.

For the issue of patient autonomy versus beneficence, I can definitely see both sides of the argument. On one hand, some may argue that by giving her the pills, I may be inadvertently promoting a lifestyle deemed unhealthy by certain societies or cultures and expose her to increased risks of sexually transmitted infections. Physicians are trained to provide health care and prevent diseases, and giving her the pills would appear to run counterintuitive to physicians. On the other hands, it may be considered and ageist attitude to assume reckless sexual activity and most of all, with the decline of medical paternalism, the patient’s autonomy in making decisions regarding her own care must be respected as long as the patient can understand and appreciate the risks involved.

In regards to confidentiality, while medical communications are not privileged, physicians have a duty to confidentiality except in cases of public harm. Breaking this confidentiality may result in lack of trust of the medical profession, and importantly, it may result in the termination of this therapeutic relationship.

In this specific scenario, I would first console the patient on sexual health, and the risks involved in being sexually active as well as guide her towards further resources if she requires help or feels uncomfortable talking to me further. In doing so I would have satisfied the rule of beneficence while also respecting patient autonomy. If the patient understands and appreciates the risks and benefits involved, I will give her the pills. There is room, I believe in this case of limited paternalism, where I may caution her to be careful and not all people have her best intentions at heart. There is no need to tell her parents if she demonstrates capacity to understand her situation and her request does not place herself in scenarios of serious harm to herself or others. Minors should be treated as autonomous beings.”