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Primum Non Nocere Dorothy A The Linacre Quarterly Volume 41 | Number 3 Article 10 August 1974 Primum Non Nocere Dorothy A. Starr Follow this and additional works at: https://epublications.marquette.edu/lnq 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 psychiatry 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 secrecy 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 information 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.
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