The Linacre Quarterly

Volume 41 | Number 3 Article 10

August 1974 Dorothy A. Starr

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Recommended Citation Starr, Dorothy A. (1974) "Primum Non Nocere," The Linacre Quarterly: Vol. 41 : No. 3 , Article 10. Available at: https://epublications.marquette.edu/lnq/vol41/iss3/10 Primum Non Nocere

Dorothy A. Starr, M.D.

Confidentiality where adoles­ ental objections, opmIOns or re­ cents are concerned is a two edged ligious convictions. For our pur­ sword poised on a thread over the poses, we are excluding those spe­ head of any outside Other who cial relationships, such as the con­ wants to live dangerously. There fessional and analytic psycho­ are two aspects of the problem; therapy, in which parents, know­ one is confidentiality from the ing that they will not be advised as to what transpires, freely con­ Dr. Starr is in the private prac­ sent to and voluntarily promote tice of in Washington, in order to achieve long range D. C., and is a member of the goals. Unfortunately, analysts Mental Health Commission. Her have sometimes not been entirely article questions the value of con­ successful in making these ground fidentiality as it applies to the rules clear to the parents. Many adolescent-therapist relationship. physicians have learned this when She examines the effect that parents react to their exclusion "secrets" have on family life. with anger, vehement criticism of psychiatry in general, and threats parents about the whole relation­ to treat the bills as that doctor ship and the 'other includes them treats their inquiries. in, for better or for worse, more Considering the rapid prolifera­ or less. tion of publicly and privately My particular concern is the supported programs to provide a confidentiality between adoles­ variety of services to individuals cents and unselected Others with­ under the age of 18, on their own out parental knowledge, without recognizance, without the knowl­ parental approval, without any edge, much less the consent, of a due process to set aside the ex­ parent or guardian, and without isting guardianship rights and judicial review, there is a dearth often in defiance of known par- of validation of the need, desir-

200 Linacre Quarterly ability and long range effects of mean individuals who I)ave passed such intervention in the parent­ their twelfth birthday and/ or child relationship. These meas­ manifested obvious physical signs ures are an intrusion into one of of puberty, have not attained a the basic functions of the family locally recognized legal status of - the protection and education emancipated minor, or their 18th of its children - and go signifi­ birthday. In today's world, 18, 19 cantly beyond the older laws reg­ and 20 year-olds are not routinely ulating child labor and school at­ self sufficient adults. Many are tendance. The older laws were still financially dependent, many publicly mandated and publicly are emotionally dependent. But enforced - in fact told the par­ the range of maturity is a con­ ent what he had to do, not the tinuum and the legal status am­ child what he could or should do, biguous, so I have excluded them. and involved no element of con­ Privileged Communication fidentiality. It is interesting that Defining confidentiality is rem­ these changes come not thirty iniscent of Humpty Dumpty's years after the end of the Hitler comment to Alice: " When I use a holacaust and a full decade be­ word it means just what I choose fore 1984. it to mean - neither more nor The rationale for waiving par­ less." The legal definition of priv­ ental knowledge or consent is that ileged communication is one be­ the adolescent is alleged to be tween parties to a confidential unable and/ or unwilling to in­ relationship such that the re­ volve the parent or guardian, and cipient can not be legally com­ the need for free access to the pelled to disclose it in court services outweighs any other con­ proceedings. The law spells out siderations. Implied in this is the the parties and specifies the re­ presumption that the services to lationships in this privilege. Law­ be rendered, and the sur­ yers advise that this has become rounding them, will be in the best so watered down in practice that interests of the individual con­ specific measures are needed to cerned. All of these premises are delineate a special psychothera­ worthy of examination. pist-patient privilege. To my First, to define our subject, knowledge, no one has addressed adolescents are individuals in the the question of who has the au­ stage of development from the be­ thority to waive privilege for an ginning of puberty to the attain­ unemancipated minor in a confi­ ment of legal majority. Unfortu­ dential relationship from which nately, the beginning age varies the parents have been excluded. and the end is a subject of legal Customary usage has required controversy. Coming of age varies parental permission for release of from one jurisdiction and purpose medical on a child to another. To be more specific, I patient - a quandary if in fact will use the term adolescents to the parent is ignorant of the ex-

August, 1974 201 istence as well as the content of lesser extent, without judicial such information. process, in secret, at his own dis­ Confidentiality per se is the cretion, with or without legisla­ quality of being confidential, pri­ tive sanction and with or without vate or secret; not for disclosure any defined professional qualifi­ to unauthorized/ outside persons; cations or license. not for publication. The Hippo­ Parental consent is still rou­ cratic Oath binds physicians to tinely sought for such momentous hold confidential that which they decisions as "Mary may/ may not learn in the course of their medi­ have milk at lunch." The school cal practice but it does not put it that requires a parental permis­ under the seal of the confessional. sion slip to transfer from Spanish Physicians have interpreted the to French requires nothing for a confidentiality with judgement counselor to embark on a quasi­ and discretion, they have decided therapy program. Failing grades when and what to tell relatives and undone homework are re­ and when circumstances warrant­ ferred to parents, emotional prob­ ed release of some or all medical lems to the guidance counselor. information to another physician A dental examination requires ap­ without a formal authorization; proval, a pelvic examination does always with judicious concern for not. The emergency treatment of the well being of the individual a severely injured unidentified concerned. Physicians have also adolescent requires the convening recognized and respected the right of a court of proper jurisdiction, of an adult patient to keep secret the harboring of a runaway child from anyone even the existence of is at the discretion of the child. the consultation (s) but custom, Suturing a small laceration re­ until recently, precluded even en­ quires the parental presence, in­ tering into a doctor-patient rela­ sertion of an IUD is none of the tionship with a child without par­ parent's business. These are end­ ental authorization. less and surely there are incon­ Dealing with adolescents in sistencies in this state of affairs. secret tends to transfer the privi­ Implicit in the rationale and lege to the recipient, to waive or justification is first the premise not as the recipient sees fit be­ that the adolescent is unable or cause adolescents are not inde­ unwilling to involve the parents. pendent adults, able to assume Adolescents themselves say so, full responsibility, pay their own frequently. "My mother would way, act unilaterally on their own kill me if she knew." "My father decisions. In these confidential would beat me up, again." "I'll relationships with an unknown kill myself if you tell them." Other, not a chosen agent of the "They don't care what I do, they parent, we have an outsider as­ hate me." "They treat me like a suming guardianship, authority baby. They never let me do any­ and discretion to a greater or thing." "I'm on my own, I ran

202 Linacre Quarterly away from home." These state­ impact of the recent federal legis­ ments are not significantly al­ lation this will soon be reportable tered if prefaced by a bland by anyone having knowledge. request for the services. The sit­ The other question is the effect uation is not significantly altered of secrets in the family system. if a bland request for services is Extensive work with families re­ followed by a psuedo sophisticat­ ported by such widely respected ed explanation such as "I've family therapists as Ackerman, abandoned out-dated middle­ Bowen, and others, does not sup­ class morality." "This is not their port the thesis that secrets are decision but mine to make." "I'm helpful or desirable in families but mature for my age and need pri­ rather the reverse. Secrets further vacy to find myself." impede communications and ag­ Conflict Between Generations gravate problems. In my own All of the above, no matter how work I have never been success­ expressed, reflects the essence of ful ~hen I erroneously got into the adolescent problem, the con­ the role of confidante to one or flict between the generations. The the other of the spouses or the major work of this period is eman­ adolescent. As to the adolescent's cipation from parental control contention that he is unable or and delineation of one's own unwilling to divulge this matter ego with control of instinctual except in strict confidence, few impulses and sublimation and of them even pause when I inter­ postponement of gratification. ject a disclaimer before they go Indulgence and immediate grati­ on to spill the super secrets. In fication belong in the nursery. fact, the profuse documentation The very fact that the adolescent of all these secrets, in and on copy is unable or unwilling to work books endless notes carelessly through a resolution of the con­ left i~ pants pockets, the numer­ flicts with the parents is the prob­ ous clues discarded in waste bas­ lem. The need for secrecy is the kets and other secure repositories, problem and a pacifier; pablum leave me quite dubious of the when the individual needs help allegation that adolescents want cracking the tough nuts. Secrecy their parents in the dark. If in thus evades the issue, is in the fact the purpose of the acting out nature of yielding to threats and is t~ precipitate interaction with appeasing demands and as such the parents, the secrecy only tends to foster regression rather forces the adolescent to move on than maturation. to something more conspicuous. If of course these statements abo~t abusive,' unfeeling, uncar­ The evidence on which legisla­ ing parents are taken literally, tion is promulgated is to be found the recipient would be well ad­ in legislative hearings. Being resi­ vised to consider reporting this dent in the District of Columbia, case of . Under the our town council is the congress

August, 1974 203 of the United States and I have outside adults promoted the ado­ reviewed a number of committee lescent process or simplified it, reports and congressional hear­ then child rearing should be left ings. The evidence consists large­ to the state experts. ly of lengthy statements by the If we assume that secrecy or advocates of the program, such confidentiality is mandatory for as directors of runaway houses, the services to be used, and they population control enthusiasts, are in themselves essential to the program planners, some qualified well being, growth and develop­ child psychiatrists, less often op­ ment of adolescents, then perhaps ponents (unless there is organized the end justifies the means which opposition), and often quite mov­ may only be indifferent. What are ing anecdotal accounts of a few these so essential and construc­ individual case histories validat­ tive services? Access to free ing the need for legislation. Since clinics, psychotherapy of various all elected officials are in favor of , contraception and child services, there is a tendency , treatment of venereal to confuse the worth of children disease and drug reactions or and the worth of the particular complications, provision of food services. There is also a tendency and shelter to runaways and in­ to confuse the need to do some­ formation about all these facilities thing with the need to do this. and services. None of these is in­ Read in their entirety, few of these herently bad in a pluralistic so­ documents would be sufficient ciety with honorable differences basis for a professional prescrip­ about those which are controver­ tion for a standard treatment. sial. If we assume that these pro­ grams and services are essential There is always an element of and beneficial, it seems reason­ self-fulfilling prophesy. The more able to look for results. services are offered with guaran­ Significant Questions tees of absolute confidence, the Has the steady increase in more adolescents are programed school counseling services de­ to the implicit assumption that creased quantitatively or qualita­ parents must not know, and the tively the emotional problems and more likely they withdraw from drop-outs, or increased the aca­ parent - adolescent communica­ demic performance or adjustment tion, and the more impaired the of the population? Have drug ed­ communications and so on round ucation programs, hot lines, and the circle. crash pads reduced the percent­ If there was some evidence that age of adolescents experimenting secrets were good for families, if with drugs and alcohol, or re­ there was some evidence that this duced the severity? Has the free served the adolescent well in and confidential provision of con­ achieving maturity, if all these traception and abortion decreased confidential relationships with unwanted pregnancies proportion-

204 Linacre Quarterly ate to the increased number of what is developmentally desir­ sexually active adolescents? Is able. If it can be documented that sexual activity, under fifteen, un­ most, or many, adolescents would der eighteen, developmentally de­ be benefited by having free access sirable? to any services without parental knowledge or approval and that it The answers are harder to come is beneficial to remove parental by than the questions. School controls - then that problem counseling is difficult to evaluate. should be faced and the parental Psychiatrists see only the fail­ role in adolescence clarified. ures, but there is no reported de­ creased need for other services. I have not addressed the prob­ Drug education programs are cur­ lems of confidentiality involving rently suspected of being how-to­ the whole triangle, adolescent, do-it courses. Sex education and parent and Other because of its birth control clinics must be ambiguity unless used in the credited with changing the ter­ sense of keeping private, not for minology from "sexual acting­ disclosure to outsiders. If it means out" to "sexually active," and, I that the adolescent is deceived by would add, deleting the use of the the Other who promises secrecy, term "girl," as in "sexually active then relays information to the teen-age woman." Contraceptives parent, it is simply dishonest and are now pushed in adolescence as not likely to be sustained. If this if this group had had the highest works the other way and the par­ incidence of illegitimate pregancy. ent confides in the Other who re­ In fact, 1969 statistics indicated veals it to the adolescent, it is that the 15 to 19 year-old cohort also likely to be a short lived re­ had only half the incidence of lationship. When any two people pregnancy per thousand to that exchange secrets about a third, it found in either the 20 to 24 year affects their relations with each group or the 25 to 29 year group. other and with the third in ways Thanks to the post-war baby not likely to increase trust and boom however, there were so communication. With an adoles­ many teenagers as to increase cent in skillful therapy the vari­ their percentage in the popula­ ous pitfalls may be avoided. The tion. If early sexual intercourse experienced therapist makes ex­ is good in itself then it may be plicit his ground rules to both wise to provide these services and adolescent and parent and is pre­ the encouragement. The major pared to work through the com­ thrust of the rationale has been plications. This is quite different rather, that either adolescents are from transferring some of the going to anyway, or want to begin ground rules to a myriad of other sexual activity, and that the only situations. Some therapists are problem is population control. able to function as the repository This does not address itself to for everyone's secrets in what

August, 1974 205 amounts to simultaneous therapy edged sword. When this confiden­ with two family members sepa­ tiality is used to conceal from the rately; this is generally regarded parent that which he is known or as technically difficult and usual­ likely to object to, the confidante ly foolhardy. Acting out adoles­ deliberately or accidently has cents are rarely considered suit­ joined forces with the adolescent able candidates for such classic against the parent, and become a therapy on an outpatient basis chum. and the more problems the ado­ lescent and the family have, the Advocates of rebellion may be more likely they are to be in less popular but the question should experienced hands, where confi­ be, "Are they doing more harm dentiality really will be a two than good?"

206 Linacre Quarterly