To Tell or Not To Tell

Lisa, a fifteen-year-old who recently moved to a different state, is being seen today for the first time by a new physician for a well-child check. He has not yet received her medical records from her former doctor.

In the exam room, she tells her new physician that she is healthy and takes no medications, only vitamins. She says she is an honors student, swims, and plays the violin. When the physician asks whether she is sexually active, she says no, but admits that she is thinking about it because she is in love with a boy from her old school. The two have been dating for a year and have recently started talking about having sex. The physician asks if they have talked about birth control, too. Lisa says they have and tells him that she started taking birth control pills a few months ago. The physician mentions the necessity of using a condom as well to guard against sexually transmitted diseases, but Lisa replies that they are both virgins, so neither has to worry about that.

Lisa's physician briefly leaves the room to let her get undressed for the exam. In the hallway, he sees Lisa's parents, who have accompanied her to the clinic. They say they must speak to him immediately and in confidence. He is surprised, but shows them to his office. There, they tell him that Lisa has congenital HIV and has been taking HIV medications that were prescribed by her former pediatrician. They also tell him that she does not know this—they have told her the medications are vitamins.

Without mentioning anything that Lisa told him in confidence, the physician tells her parents that he thinks it's time they told her she has HIV. Her parents get very angry. They insist that Lisa is still a child, and there is no reason to tell her yet. The physician mentions Lisa's boyfriend and the length of their relationship. He reminds them that Lisa's boyfriend will be at risk if he and Lisa have sexual contact.

Lisa's parents say they know all about her boyfriend, but they insist the relationship is not mature enough for them to be thinking about sex—all they do is play video games together. They adamantly disagree with the physician's view that Lisa is old enough to know her HIV status and say they will sue him if he tells her without their permission.

What should Lisa's physician do?

• Commentary
• Lekeisha Terrell (bio)

This case raises important issues: Lisa has the right to know she is HIV positive; her boyfriend has the right to know he is exposed to HIV; and her parents have the right to confidentiality about their HIV status. The physician's goal is to do what is in the best interest of the patient. In this case, Lisa should be informed of her HIV-positive status. After the medical interview, her physician should be able to assess whether she is a mature minor and intellectually able to understand the information presented to her.

Lisa is an adolescent transitioning from childhood to adulthood. During this maturation process, physical and intellectual changes allow adolescents to make autonomous decisions. The physician has a moral and ethical obligation to discuss health and illness with a child patient and is supported by U.S. laws, policies, and previous court decisions. The American Academy of Pediatrics recommends that all adolescents and some school-age children know their HIV status. Disclosure improves adolescent care by increasing the bond of trust. It promotes patient autonomy by showing respect for an adolescent's emerging capacity to understand and by increasing an adolescent's participation in his or her own care. Research has shown adolescents have improved adherence to a plan and improved health outcomes when they are involved in their medical decisions. However, disclosure may cause Lisa to distrust her parents because they did not tell her sooner.

Lisa was born with HIV. This means that at least her mother and possibly her father are HIV positive. Both her mother and father have a right to confidentiality about...