Informed consent in adolescents is a special case of this common bioethical issue, requiring particular thoughtfulness in the physician due to differences in the physician-patient relationship between adults and children or adolescents. The assessment of competence, or capacity in legal terms, is more problematic in children and adolescents. They mature at different rates, and their values and ability to appreciate future events change with time. Their ability to understand and appreciate situations varies more with the specific circumstances than it does in adults. Therefore, the designation “mature minor” also varies with circumstance, not age. A 10 year old may very well be able to understand and agree to treatment for an ear infection, but perhaps not the options involved in cancer treatment.
An additional difficulty is related to the anorexia itself. Part of the disease is a denial of need for treatment. That, and the fact that a nutritionally starved brain may not be functioning normally, make determination of competence in a patient like Kelsey very difficult. The idea of resistance to, rather than refusal of treatment, may be helpful, as noted in MacDonald (2002). One cannot fall back on legalities although there are provincial and territorial differences in legal age of consent. In practice, a person of any age is deemed capable unless shown to be incapable.
The ethical issues regarding confidentiality are somewhat clearer. Assuming Kelsey is competent, she has the same right to confidentiality as anyone else. Dr. Burnside was quite correct in asking to speak alone with his patient, but he probably should have taken the opportunity to discuss confidentiality with Kelsey. He could ask, and would probably receive, her permission to include her mother in treatment discussions. However, if she refuses, what should he do?
A final issue is Dr. Burnside’s loss of control, resulting in his angry outburst. This probably reflects his discomfort and sense that he cannot handle the situation. It is much easier to talk to the mother, as we shall see later. Should he have apologized to Kelsey? At least he is aware of his feelings and actions. Self-awareness is an important part of communication skills and physicians who feel that they are always emotionally and value-neutral are deluding themselves. Knowledge of one’s limitations and willingness to seek help are part of expected professional behaviour.
The following literature addresses the issues of consent and confidentiality with adolescents: