Clinical Commentary

This case illustrates the complex issues that surround confidentiality and disclosure that often confront and confound psychiatrists when treating adolescents or young adults. Miss M seems to be a bright young girl who has the foresight to seek help from her school counsellor after experiencing emotionally distressing symptoms. She is naturally worried about the stigma that she may face from her peers and hence wants to keep her visit to the counsellor and later psychiatrist confidential. She also does not want her parents involved in her treatment.

Dr. C is a child psychiatrist with specialised training in anxiety disorders. Based on the history obtained from Miss. M, a diagnosis of anxiety disorder with depressive symptoms is made. When Miss M makes a request not to inform her parents about her treatment, Dr. C is faced with an ethical dilemma. On the one hand, according to Singapore Medical Council Ethical Code and Ethical guidelines, if a patient is a minor, information regarding their condition and treatment should be explained to their parent or guardian.¹ On the other hand, the fear of disclosure would most likely prompt Miss M to forego healthcare services, risking a worsening of symptoms. Dr. C rightly feels that it is important to build the patient’s trust during the first contact. Moreover, she is help-seeking and seems to have the maturity and intelligence to make treatment decisions for herself. Most importantly, she does not pose a risk to herself or others. Taking all these factors into account, Dr. C decides to respect Miss. M’s request for confidentiality, albeit a bit reluctantly, while explaining to Miss M that involving her parents in her treatment may give her additional support and enhance her recovery. A point to note is that her parents are not completely in the dark about the treatment since they receive bills from the clinic and are paying for her treatment.

However, over the course of therapy, Miss M reveals to Dr. C that she has been sexually active and is pregnant as a result of it. Subsequently, she undergoes a medical termination of pregnancy. According to the Singapore Abortion Act law, there is no legal requirement for parental consent involving termination of pregnancy in minors. However, girls below the age of 16 years are required to go through mandatory counselling at the Health Promotion Board Counselling Centre. So legally, Dr. C is not obligated to report Miss C’s abortion to her parents. Never-the less, it is a moral and ethical dilemma for the treating psychiatrist. After gaining Miss M’s trust and confidence, Dr. C should have continued to encourage her to talk to her parents about her treatment. Another option would have been to explore the possibility of involving another family member whom Miss M was close to and felt comfortable sharing information about her treatment with. It would also be important to talk to the patient at the outset about the limits placed on confidentiality and outline the possible scenarios where he would have the duty to disclose and document all these discussions clearly in the case records.

Confidential health services are essential in promoting young persons’ health. Teenagers are at a critical stage of development both emotionally and physically and are beginning to establish their autonomy and self-determination. Although most teenagers seek routine medical care with their parents’ knowledge, making parental notification mandatory will drastically reduce the likelihood that teens will seek timely treatment.² However, the potential of risk to self or others overrides confidentiality and calls upon the psychiatrist to make this critical decision based on sound clinical judgement, taking into account the best interests of the patient.