TESTIMONY
BEFORE THE
HOUSE JUDICIARY COMMITTEE
PRESENTED BY:
JONATHAN D. KLEIN, MD, MPH, FAAP
ASSOCIATE PROFESSOR
DEPARTMENT OF PEDIATRICS
UNIVERSITY OF ROCHESTER SCHOOL OF MEDICINE
On behalf of the:
AMERICAN ACADEMY OF PEDIATRICS
SOCIETY FOR ADOLESCENT MEDICINE
ADVOCATES FOR YOUTH
MAY 27, 1999
Good morning, Mr. Chairman and members of the Committee. I am Dr. Jonathan Klein, a practicing pediatrician who has taken care of adolescents for the past 15 years. I am also an associate professor in the Department of Pediatrics at the University of Rochester School of Medicine. In the 15 years that I have engaged in the health care of adolescents, I have been involved with their families, extended families and other caregivers. I have taken care of adolescents in clinical settings and in institutional settings. Within organized medicine and other social service organizations, I have served on numerous national, regional and local advisory and professional committees on many issues regarding adolescent health and conferred with many colleagues across the nation on these very tough issues.
I am speaking today on behalf of the American Academy of Pediatrics, an organization representing 55,000 pediatricians throughout the nation. In addition, I am representing the Society for Adolescent Medicine, an organization of over 1500 physicians, nurses, psychologists, social workers, nutritionists and others involved in service delivery, teaching or research on the welfare of adolescents and Advocates for Youth, a national non-profit organization dedicated to helping young people make informed and responsible decisions about their sexual and reproductive health. It provides information, training, and advocacy to youth serving organizations, policy makers and the media in the US and internationally.
It is from these perspectives and perhaps most importantly as a parent that I am here today to express our concerns about the pending legislation, H.R. 1218, the "Child Custody Protection Act." I would like to thank the Committee for this opportunity to present this statement as Congress continues to debate this issue of significance to adolescent health care.
OVERVIEW:
The American Academy of Pediatrics firmly believes that parents should be involved in and responsible for assuring medical care for our children. Moreover, we would agree that as parents we ordinarily act in the best interests of our children and that minors benefit from our advice and the emotional support we provide as parents. We strongly encourage and hope that adolescents communicate with and involve their parents or other trusted adults in important health care decisions affecting their lives. This includes those regarding pregnancy and pregnancy termination. We know and research confirms that most adolescents do so voluntarily. This is predicated not by laws but on the quality of their relationships. By its very nature family communication is a family responsibility. Adolescents who live in warm, loving, caring environments, who feel supported by their parents and their parents with them, will in most instances communicate with their parents in a crisis including the disclosure of a pregnancy.
My role as a pediatrician is to support, encourage, strengthen and enhance parental communication and involvement in adolescent decisions without compromising the ethics and integrity of my relationship with adolescent patients.
The stated intent by those who support mandatory parental consent laws is that it enhances family communication as well as parental involvement and responsibility. However, the evidence does not support that these laws have that desired effect. To the contrary, there is evidence that these laws may have an adverse impact on some families and that it increases the risk of medical and psychological harm to adolescents. According to the American Academy of Pediatrics, "[i]nvoluntary parental notification can precipitate a family crisis characterized by severe parental anger and rejection of the minor and her partner. One third of minors who do not inform parents already have experienced family violence and fear it will recur. Research on abusive and dysfunctional families shows that violence is at its worse during a family member's pregnancy and during the adolescence of the family's children."
CONFIDENTIALITY OF CARE:
I would like to turn my attention to the issue of confidentiality -- whether adolescents can access health care services without parental consent. The American Academy of Pediatrics, and other medical and public health groups firmly believe that young people must have access to confidential health care services -- including reproductive health care and abortion services. Every one of our states' laws also provide confidential access to some services for young people, whether for child abuse, STDs, drug addiction or reproductive health care. Concern about confidentiality is one of the primary reasons young people delay seeking health services for sensitive issues, whether for an unintended pregnancy or for other reasons. While parental involvement is very desirable, and should be encouraged, it may not always be feasible and it should not be legislated. Young people must be able to receive health care expeditiously and confidentially.
Most adolescents will seek medical care with their parent or parents' knowledge. Making services contingent on parental involvement mandatory (either parental consent or notification) however, may drastically affect adolescent decision-making. Mandatory parental consent or notification reduces the likelihood that young people will seek timely treatment for sensitive health issues. In a regional survey of suburban adolescents, only 45 percent said they would seek medical care for sexually transmitted diseases, drug abuse or birth control if they were forced to notify their parents.
A teen struggling with concerns over his or her sexual health may be reluctant to share these concerns with a parent for fear of embarrassment, disapproval, or possible violence. A parent or relative may even be the cause or focus of the teen's emotional or physical problems. The guarantee of confidentiality and the adolescent' s awareness of this guarantee are both essential in helping adolescents to seek health care.
For these reasons, physicians strongly support adolescents' ability to access confidential health care. A national survey conducted by the American Medical Association (AMA) found that physicians favor confidentiality for adolescents. A regional survey of pediatricians showed strong backing of confidential health services for adolescents. Of the physicians surveyed, 75 percent favored confidential treatment for adolescents. Pediatricians describe confidentiality as "essential" in ensuring that patients share necessary and factual information with their health care provider. This is especially important if we are to reduce the incidence of adolescent suicide, substance abuse, sexually transmitted diseases and unintended pregnancies.
Many influential health care organizations support the provision of confidential health services for adolescents, here is what they say:
The American Academy of Pediatrics. "A general policy guaranteeing confidentiality for the teenager, except in life-threatening situations, should be clearly stated to the parent and the adolescent at the initiation of the professional relationship, either verbally or in writing."
The Society for Adolescent Medicine. "The most practical reason for clinicians to grant confidentiality to adolescent patients is to facilitate accurate diagnosis and appropriate treatment.... If an assurance of confidentiality is not extended , this may create an obstacle to care since that adolescent may withhold information, delay entry into care, or refuse care."
The American Medical Association. "The AMA reaffirms that confidential care for adolescents is critical to improving their health. The AMA encourages physicians to involve parents in the medical care of the adolescent patient, when it would be in the best interest of the adolescent. When in the opinion of the physician, parental involvement would not be beneficial, parental consent or notification should not be a barrier to care."
The AMA also notes that, because "the need for privacy may be compelling, minors may be driven to desperate measures to maintain the confidentiality of their pregnancies. They may run away from home, obtain a "back alley" abortion, or resort to a self-induced abortion. The desire to maintain secrecy has been one of the leading reasons for illegal abortion since..1973."
American College of Physicians. "Physicians should be knowledgeable about state laws governing the rights of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment. The physician must not release information without the patient's consent unless required by the law or if there is a duty to warn another.
The American Public Health Association. APHA "urges that...confidential health services (be) tailored to the needs of adolescents, including sexually active adolescents, adolescents considering sexual intercourse, and those seeking information, counseling, or services related to preventing, continuing or terminating a pregnancy."
Of course, it is important for young people who are facing a health-related crisis to be able to turn to someone dependable, someone they trust, to help them decide what is best. Many, many times that person is a parent. Teenagers facing a crisis pregnancy should be encouraged to involve a parent, and many do so. In fact, over 75 percent of teens under age 16 involve at least one parent in their decision, even in states that do not mandate them to do so. In some populations as many as 91% of teenagers younger than 18 years voluntarily consulted a parent or "parent surrogate" about a pregnancy decision.
All too often, however, young women know that their parents would be overwhelmed angry, distraught or disappointed if they knew about the crisis pregnancy. Fear of emotional or physical abuse, including being thrown out of the house, are among the major reasons teenagers say they are afraid to tell their parents about a pregnancy. Young women who are afraid to involve their parents very often turn to another adult in times of difficulty. One study shows that, of young women who did not involve a parent in their abortion decision, over half turned to another adult; 15 percent of these young women involved a step-parent or other adult relative. In my own practice, I have had the situation arise in which an adult female sibling or cousin has been the person the adolescent wanted me to call into the consultation based on the fear of anger and rejection from her mother.
H.R. 1218 would harm young women who are most afraid to involve their parents in an abortion decision and who most need the support of other adults in their lives. Instead of encouraging young people to involve adults whom they trust, the law would discourage such communication. The bill would have the unintentional outcome of placing a chilling effect on teenagers' ability to talk openly with adults -- including family members and medical providers -- because it sends a message that adults who help young people grapple with difficult decisions are criminals. This disincentive is extremely dangerous for those young people most in need of support and guidance in a difficult time when they cannot involve their parents.
THE BALANCE BETWEEN STATES AND PARENT'S RIGHTS
This legislation is not only troublesome with regard to its effect on confidential medical care for teens; it is also a harmful and potentially dangerous bill from the perspective of its intent and its potential effect on states and individual rights.
As currently written, H.R. 1218, would apply one state's laws to another state. Young women would be required to abide by the "original" state's (the state where the young woman resides) law regardless of where they seek medical care. There are many reasons why women travel to obtain an abortion including concerns about confidentiality and consent. An adult who accompanies a young woman to a legal, accessible, and affordable abortion provider would be placed in the position of risky criminal sanctions.
Applying the laws from one state on women who seek medical care in another state raises important questions about state's rights. As a physician, I have the responsibility to refer patients to the best care possible. In my experience, physicians in any other medical procedure are not subject to guidelines that prohibit proceeding with medical care in one state based on guidelines from the referring state. In addition, in certain metropolitan areas physicians have a license to practice in more than one jurisdiction, such as Washington, D.C., Maryland, and Virginia. In other metropolitan areas that cross state lines most of the health services are in one state, and not the other. This would burden families and would result in significant disruption of the relationships between doctors and their patients, too. Again, consider your own Greater Metropolitan Washington community -- what would happen if a teen took the Metro subway or bus from Falls Church, Virginia to Washington, D.C.? Would an adult who loaned the teenager Metro fare be liable?
This law would be extraordinarily difficult to enforce. Does the law only apply to women who travel to another state in order to exercise their constitutional right to health care? I am afraid that there may be eventual implications for young women who are temporarily living outside their home state because of travel, education or employment.
It would be very difficult for the state to prove that young women are seeking to circumvent parental consent or notification laws. I worry about the legal ramifications for the adult who is traveling with the young woman, who may believe that the home state parental consent or notification laws have been followed.
Moreover, as a pediatrician, I am concerned about the effect on and responsibilities to the health care providers involved: the doctor's responsibility when providing abortion services to women of any age from out-of-state. Health care providers have a "fiduciary duty" (the highest degree of a legal obligation or duty) to protect the confidentiality of their patients and a number of federal and state statutes mandate the confidentiality of medical records and information. One of the most common requirements is found in state licensing statues for physicians. For example, in Colorado, a physician who violated a patient's confidentiality is subject to disciplinary action, including revocation of his/her license. Other states mandate that health records must be kept confidential and cannot be released without the patient's consent. I am very concerned that Congress may put health care providers in the position where they must violate their state's confidentiality statutes in order to meet the obligations of a neighboring state.
CONCLUSION
In conclusion, I reiterate a statement previously made by the immediate past president of the Society for Adolescent Medicine: "[C]learly the proposed bill is designed to eliminate this [abortion]option for many adolescents. Adolescents who cannot rely on one or both parents to help them through the trauma of a pregnancy and who, for legal or geographical reasons, may need to go to an adjoining state for termination, are effectively precluded from receiving help from those (such as other relative, health professional, or even the clergy) who would be there to help them. In essence, this law would put adolescents in the position of having to take care of themselves (possibly traveling long distances in the process), without supportive care during a traumatic time in their lives."
As physician, a teacher, and most of all, as a parent, who is concerned about the quality and safety of health care for my daughter as well as for the quality and safety of health care for all adolescents in this country, I urge you to reject H.R. 1218.
Thank-you. I would be happy to answer any questions you may have.
REFERENCES
1. Gans, J.E. McManus, M.A., Newacheck, P.W. Profiles of Adolescent Health
Services, Vol. 2, Adolescent Health Care: Use Costs and Problems of Access AMA:1991, Wash., D.C. at 52.
2. Marks A. Malizio, J. Hoch, J. Brody, R. & Fisher, M., Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population, J of Pediatrics 1983; 102: 456-460.
3. Gans J.E. McManus, M.A. Newacheck, P.W. Profiles of Adolescent Health Services, Vol. 2., Adolescent Health Care: Use Costs and Problems of Access, AMA: 1991, Wash. D.C. at 53.
4. Resnick, M.D., Litman, T.J. and Blum, R.W. Physicians attitudes towards
confidentiality of treatment for adolescents: findings from the Upper Midwest Regional Survey, J of Adol. Health, 1992; 13:616-22.
5. Gans, J.E. Compendium on Reproductive Health Issues Affecting Adolescents, AMA:1996, Wash. D.C. at 10.
6. Id.
7. Id.
8. Id.
9. American College of Legal Medicine, Legal Medicine at 278 (1995).
10. Colo.Rev.Stat 25-4-1409 (2) (1995). The statute does not address physician protection of adolescent patients' confidentiality.
11. American Medical Association. Council on Ethical and Judicial Affairs. "Mandatory Parental Consent to Abortion." JAMA. Vol. 269. No.1, January 6, 1993 p. 83