Ethical and bioethical dilemmas in adolescent health care

Abstracts

The aim of this study was to identify the ethical and bioethical conflicts involved in adolescent health care, as described in the literature. Systematic review utilizing qualitative analysis, via the technique of thematic analysis, was employed. The databases utilized and the descriptors are presented in Methodology. The area includes adolescent patients, who, according to the World Health Organization, range from the ages of 10 to almost 20 and, under the Statute of the Child and Adolescent, from 10 to 18 years of age. Thus the study involves patients with such broad age ranges and with particularities derived from being no longer a child but not yet an adult. This fact requires different medical specialists and health professionals in caring for these patients, as well as knowledge of ethical, bioethical and legal aspects involved in health care.

Personal autonomy; Adolescent health; Ethics; Bioethics

Objetivou-se, neste trabalho, identificar os conflitos éticos e bioéticos envolvidos na atenção à saúde de pacientes adolescentes, que são descritos na literatura. Trata-se de revisão sistemática que empregou a análise qualitativa, por meio da técnica de análise temática. As bases de dados utilizadas e os descritores são apresentados na metodologia. Essa temática abrange pacientes adolescentes, considerados dentro da faixa dos 10 aos 20 anos incompletos, segundo a Organização Mundial da Saúde, e dos 12 aos 18 anos, de acordo com o Estatuto da Criança e do Adolescente. Assim, o estudo envolve pacientes com intervalos de idade bastante amplos e com particularidades decorrentes da fase de transição entre não ser mais criança e ainda não ter atingido a idade adulta. Tais especificidades exigem não apenas diferentes especialidades médicas e das demais áreas da saúde, mas também o conhecimento dos aspectos éticos, bioéticos e legais envolvidos na atenção à saúde desses pacientes.

Autonomia pessoal; Saúde do adolescente; Ética; Bioética

Este trabajo tuvo como objetivo identificar los conflictos éticos y bioéticos descriptos en la literatura, implicados en la atención de la salud de pacientes adolescentes. Se trata de una revisión sistemática que utilizó el análisis cualitativo, por medio de la técnica de análisis de la temática. Las bases de datos empleadas y los descriptores son presentados en la metodología. Esta temática incluye pacientes adolescentes, los cuales según la Organización Mundial de la Salud abarca las edades de 10 años a 20 años incompletos y, según el Estatuto del Niño y del Adolescente, de los 12 a los 18 años. Así, el estudio implica pacientes con intervalos de edad amplios y con particularidades resultantes de la fase de transición entre no ser más un niño, ni tampoco ser un adulto. Este hecho exige diferentes especialidades médicas y de profesionales de la salud en el cuidado de estos pacientes, así como el conocimiento de los aspectos éticos, bioéticos y legales involucrados en la atención de la salud.

Autonomía personal; Salud del adolescente; Ética; Bioética

In adolescence, there is a number of conflict situations in which the rules established are insufficient to clearly answer the ethical questions that arise in inter-relationships of young people in this age group with society. The codes and laws also are not sufficient so that health professionals can address these issues. Thus, bioethics appears as a useful tool to help equate them ¹.

Autonomy is one of the pillars of bioethics in the context of health care, it concerns the patient's decision making power on issues related to their own health. However, under certain conditions, such autonomy may be limited ², and it is up to the physician and other health professionals, to care and to protect from harm. When the risk of death is imminent, this protection may result in paternalistic actions; in this case the principle of beneficence precedes that of autonomy because, according to the fundamental principles expressed in the first chapter of the Code of Medical Ethics (“Código de Ética Médica” - CEM) ³, the professional must respect the decision as long as this decision is scientifically correct and adequate to the case, because the physician cannot put the patient's life in risk.

However, due to the respect for the autonomy of the patient, the doctor can be put in difficult situations, requiring discernment to decide on issues related to health, self-care and its impact on the individual who is under his care. Many professionals claim that adolescent patients, given their young age, are not able to take responsibility for their own health and should therefore pass the scrutiny of their legal representatives. In practice, however, the professional can not guarantee that these tutors really seek the benefit of minors under their guardianship; thus, this proposition can be questioned ¹.

Also with respect to autonomy, several studies show that teenagers delay seeking medical help, for fear that the content of their reports in consultation with a professional may be revealed relatives ⁴. For the physician, secrecy in these calls is important, as these patients, knowing they will have their information exposed, may not want to report their health problems, or may omit important information for proper diagnosis and treatment, which can compromise the doctor-patient relationship, which must be based on confidentiality and loyalty.

The CEM, in its article 74, and the Statute of Children and Adolescents (“Estatuto da Criança e do Adolescente” - ECA) ⁵, in Article 17, ensure the professional secrecy with regard to underage patients who are capable to discern. Exception to this rule is the possibility of damage to the health of the patient ³. Therefore, in seeking the confidentiality of the professional, teenagers have not only guarantees the Brazilian legislation, as well as the Constitution of the Federative Republic of Brazil (Constituição da República Federativa do Brasil) ⁶ and medical deontology ³.

Later, still in the area of ethics, Article 73 of the CEM vetoes the doctor from disclosing patient information, the breach of confidentiality being permitted only due to legal cause, legal duty or written authorization from the patient ³. According to the Brazilian Criminal Code (“Código Penal” - CP) ⁷, in Article 154, the confidentiality and privacy of information are guaranteed in all professions. The violation of the law results in the penalty of imprisonment from three months to one year or a fine.

In addition, the secrecy has always been considered a mandatory moral characteristic of the physician, a right and a duty, i.e. a right of the patient that generates the duty of the physician, but no obligation. Thus, its breach is justified in case of damage to the patient or potential harm to others not known to the physician, that is, society. However, the loss of confidentiality can result not only from legal obligations, but also from the breakdown of doctor-patient relationship ⁸.

Cases of sexual abuse, which in most cases is practiced by relatives or people close to the patient, put the physician in a conflict. The obligation of the health team of the medical service is to report such cases to the Guardian Council, because if they do not, they will be behaving as accomplices to the aggression or being careless with such situations. This approach can often aggravate the situation of the adolescent without protection, especially in a country like Brazil, where there are no effective policies to ensure the safety of these young people and the due support to overcome trauma ⁹.

Sexual abuse, violence, labor exploration and the neglect toward these young people are configured as mistreatment. Any of these situations must be denounced by the physician, if they are noticed during the consultation or examination. However, even under the protection of this legal determination, the professional does not stop living the dilemmas from that decision.

Another conflict situation is the registration of patient information in medical records. Despite being owned by the health service user, the data contained in medical records can be accessed by other service professionals as well as parents, as legal representatives. Faced with the possibility of breach of confidentiality, it is observed that many professionals omit facts and tests in order to protect adolescents ⁹.

In addition to autonomy, other canons of principialist bioethics are beneficence and non-maleficence. Beneficence concerns the protection and defense of the rights of others, to seek to prevent others from suffering damage, to eliminate the conditions that cause harm to others, to help inapt people, to rescue people at risk; i.e., it is applying the resources of medicine to cure, relieve suffering, improve well-being. Non-maleficence requires to not intentionally practice actions or harmful acts that cause harm to the patient ¹⁰.

The principles cited aid the difficult decisions in the event of terminal illness. Faced with a terminal picture, where the adolescent patient asks the health professional not to extend their suffering by refusing treatment, the physician is often faced with a moral dilemma. Despite knowing that the ideal for that patient is the application of palliative measures, the doctor can not decide for this conduct if the legal representatives of the patient does not agree with it, opting for treatment. According to the Brazilian Federal Council of Medicine (“Conselho Federal de Medicina” - CFM) ³, right conduct would result from consideration of family, considering the principle of autonomy of the patient and what the medical staff considers indicated in the patient's health condition ¹⁰. It is noteworthy that, in cases of terminal illness, the principle of non-maleficence usually overlaps that of beneficence; i.e., one should assess whether any conduct will bring more harm than good to the patient. In this case, it ceases to exercise such conduct not to injure or cause harm to the patient.

Another issue involving medical ethics and bioethical principles is blood transfusion in Jehovah's Witnesses, with the patient in life-threatening situation in which there is no time to transfer them to committees of hospital bonds, which would make viable the possibility of alternative treatment with recombinant interleukin-11, aminocaproic and tranexamic acids, tissue adhesives, volume expanders, colloid, and hemostatic instruments such as electrocautery, in order to replace the need for blood transfusion ¹¹. As there is no time for judicial intervention and in view of the refusal of the patient and the legal representatives, the professional must follow the terms of the fifth chapter of the CEM ³, articles 31 and 32: proceed with the blood transfusion and preserve life. When the procedure is elective and there is proven need for it, it will compete to the hospital to request the legal decision to proceed with hemotherapy if it is refused by the legal representatives of the patient ¹².

Given the above, it is explicit the importance of discussing this issue - the ethical and bioethical dilemmas - in the context of attention to adolescent patients, which is what is intended in this study. According to the World Health Organization (WHO), adolescence covers ages 10 to 20 years incomplete ¹³. In Brazil, this period extends from 12 to 18 years, according to the ⁵. It is noteworthy that these age groups have wide age ranges, and whose characteristics derive from the transition between not being a child anymore and has not yet having reached adulthood. This does require a specific interdisciplinary approach in the health care of these patients.

Methods

A systematic literature review was performed using the databases: Virtual Health Library (“Biblioteca Virtual em Saúde” - BVS / Bireme); Scientific Electronic Library Online (SciELO); periodicals database portal of the Higher Education Personnel Training Coordination (“Coordenação de Aperfeiçoamento de Pessoal de Nível Superior “ - Capes), and Google Scholar. The descriptors used were (in Portuguese, the English translation is in brackets) : “autonomia pessoal e profissional” (personal and professional autonomy); “consulta médica” (medical consultation); “atendimento médico” (medical care); “ética” (ethics); “bioética” (bioethics); “hebiatria” (adolescent health).

The search strategy consisted in finding articles in the mentioned databases and by manual search in reference lists of identified articles in the period May to October 2013 with no restriction on the language and the year of publication. Then the works were selected by the reading of the abstracts and the analysis by two researchers with subsequent verification according to the inclusion criteria, i.e., articles that discuss the theme from the Brazilian reality, considering the CEM 3, the Brazilian CP 7 and the ECA 5, in the light of ethics and bioethics, and which involved the adolescent population.

The data survey was conducted by researchers through standardized forms containing the following topics: author; year of publication; study design; region of the country; sample; ethical and bioethical dilemma addressed in the study; purpose of the article; limitation and external validity of the articles. To assess the quality of the articles, we used qualitative thematic content analysis 14, formulated in three stages: 1) pre-analysis; 2) exploration of the material; 3) interpretation of the results. ¹⁴, formulated in three stages: 1) pre-analysis; 2) exploration of the material; 3) interpretation of the results.

The pre-analysis was divided into floating reading, defined by the intensive reading of the material, in which the universe studied reaches completeness, representativity, homogeneity and relevance; in the constitution of the corpus or choice of documents, and in formulating hypotheses and objectives. Exploration of the material is the stage where the raw data of the material under analysis were coded and classified in thematic units in order to indicate the core of understanding the text. In interpreting the results, it proceeded to check the frequency of these units, allowing to emphasize the information to be analyzed.

Results and discussion

After the survey of the database and with the descriptors mentioned in the methods, 12,500 articles ere found, but 12.460 but discarded after reading the title. The remaining 40 papers, after reading the abstracts, were restricted to 12 articles, which were read in full and discussed among researchers. Form this analytical process 5 articles were found that met the inclusion criteria. After exhaustive reading of these works, hypotheses were formulated.

Figure 1
Flowchart of the selection of studies

Pre-analysis

Hypotheses: cases of violence (sexual and psychological abuse) experienced by adolescents should be reported by health professionals without representing breach of confidentiality; cases of HIV and abortion must be disclosed to family or sexual partners; teens consider respect for autonomy and fundamental confidentiality in health care; teens, even before age 15, should have access to contraception; the rape presumption ceases to exist if the young teenager wishes so, and the professional agrees to the conduct.

Classification of the material

Three units of data analysis were defined:

• Physician-Patient relationship (characteristics of the consultation by adolescents)

• Sexual activity in adolescents under the age of 14

• Bioethical dilemmas in the physician-patient relationship, when adolescents experience issues related to violence.

Interpretation

Frame 1, below, shows that the principles and values of autonomy, confidentiality, privacy and benevolence were discussed by all authors. It was observed that in most cases of violence, whether sexual, psychological or physical, the family does not agree with the act of notification by the professional. It is known that the notification is, in addition to a regulatory and legal duty, an act of kindness by the physician, existing conflict between the autonomy of the family and the paternalistic legal duty act by the technician. Some health professionals regard the notification as disclosure of information, confidentiality and privacy of the patient. It is therefore necessary to consider the extremes of conflict. The cat of complaint of a teenager who has sex in its sole discretion, and regularly follows the recommended care for their health, can be interpreted as the technical breach of confidentiality and disregard the principle of patient autonomy. As for the situations typified as sexual, psychological or physical abuse, these require the duty of notification.

On the one hand, it is conduct typified in Article 154 of the Brazilian Penal Code ⁷ as a crime of breach of professional secrecy. However, the same Article provides that in cases of fair cause, the offense is not configured. Moreover, one cannot forget the ninth chapter of CEM ³, article 73, makes the situation even more peaceful by expressly stating that, in cases of just cause legal duty or written authorization from the patients, confidentiality may be broken.

On the other hand, one can stand before the crime of bodily injury, typified in Article 129 of the Penal Code 7. In this case, the injury is qualified by § 9 as follows: If the injury is done to ascendant, descendant, brother, spouse or partner, or with whom the author lives or has lived, or, if the agent takes advantage of domestic relations, cohabitation or hospitality: (Writing amended by Law No. 11,340, 2006) Penalty - detention of 3 (three) months to three (3) years. (Writing amended by Law No. 11,340, 2006).

Thus, it is clear that the legal good "physical, moral or psychological integrity" of adolescents should override professional secrecy. The victim - in this case the teenager - is the most injured part in the situation. There is no doubt that should receive the necessary care.

The ECA ⁵ ECA also confirms the importance of legal and judicial protection with regard to violence against children and adolescents, both in the general clause of Article 5 as in Articles 101, paragraph 2, and 173, which set out the measures to be taken in cases cited. Also, it is stressed that, as reported, it is the duty of health professionals to inform the competent authorities about any abuse or violence to the child or adolescent, under the risk of penalty. So in addition to being forced to break the professional secrecy in such cases, the health professional is compelled by legal rule to denounce them. Clearly, any theory which sees the situation as illegal disclosure of information does not find ethical or legal grounds.

Frame 1
Description of the ethical aspects identified in the studies

Author(s)	Type of study	Sample	Autonomy / secrecy / privacy	Beneficence
Gonçalves HS, Ferreira AL 15	Descriptive	Report of professional experience	Conflict when the patient and the family do not wish the notification of the violence Paternalism	Notification duty
Taquette RS, Vilhena MM, Silva MM, Vale PM16	Descriptive	74 professionals	Need to breach of confidentiality to the family Conflict when patient and family do not want the notification of violence Comment the information with other peers Paternalism	Advise on sexual health and contraception To ensure the secrecy of information obtained in the consultation, except in situations where this must be broken
Brandão ER, Heilborn ML 17	Series of cases	13 youngsters and 12 relatives	Adolescent with unsafe sex Abortion decision by the teenager Preserve the identity of the teenager who aborted	Advise on sexual health and contraception Encourage the adolescent to tell the family about her decision to abort
Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes R 18	Cross cut	201 adolescents with incomplete abortion	Abortion decision by the teenager Preserve the identity of the teenager who aborted Not to provide sensitive information to people not connected to the case	Provide emergency medical assistance in the event of abortion Promote sexual health
Taquette RS 19	Review of literature	_	Adolescent with unsafe sex Breach of confidentiality in the case of HIV, pregnancy, abortion, violence against (a) teenager Preserve the adolescent's right to privacy Preserve the confidentiality of information	Advise on sexual health and contraception Care for the teenager without moral or religious prejudice

Physicians should exercise beneficence in keeping the information registered in the records confidential; likewise, they should not discuss the cases of patients beyond the context of health care of these adolescents. In addition, it is also a right of patients to request information about contraceptive methods and sex education, and the physician should guide them in the best possible way. Under Article 73 of the CEM ³, it is forbidden to physicians to disclose medical facts brought to their attention in the exercise of their profession, except for a just reason, legal duty or consent in writing of the patient. In article 74, it is forbidden to the physician to disclose professional secrecy related to under age patients, including to parents or legal representatives, provided that the minor has capacity of discernment, unless the non-disclosure may cause harm to the patient. In cases of HIV infection and illicit drug use, for example, communication with sexual partners and family members can be considered fair cause ¹⁶.

Brandão and Heilborn ¹⁷, in a descriptive study of middle-class young people from 18 to 24 on the theme of sexuality, pregnancy and abortion, they observed that sexual initiation concurrent with the choice of contraception by these teenagers is a way of exercising autonomy. The preponderance of professional secrecy about sexual and reproductive rights of adolescent patients can still be questioned in cases of pregnancy or therapeutic or humanitarian abortion. That's because the family should support the process of pregnancy or a possible abortion, as permitted by law.

The practice of abortion is a crime typified in Articles 124 to 128 of the Brazilian Criminal Code. Thus, only the therapeutic or humanitarian abortion may be in question. The therapeutic or necessary abortion occurs when the practice becomes essential to save the mother's life. The risk of death of the pregnant woman excludes unlawfulness, the state of necessity under the Penal Code, in Article 24.

humanitarian abortion occurs in cases where the pregnant woman was the victim of rape or sexual violence. In such cases, abortion is permitted on the basis of ethical and humanitarian aspects, being an exclusive of guilt for lack of enforceability of a different conduct, institute also provided by the Criminal Code, Article 22. These exceptions are provided for in Article 128 of the Law and, although the article uses the word "medical", it should be interpreted more broadly. Thus wherein there is an imminent state of necessity of the pregnant woman, it is possible for the abortion to be performed by a non-physician.

There is still one more recent possibility of abortion. This is the anencephalic fetus abortion, for which there is no specific legal provision. Thus, the situation resulted in the proposal of Accusation of Breach of a Fundamental Precept (“Arguição de Descumprimento de Preceito Fundamental” - ADPF) 54, judged by the Federal Supreme Court (“Superior Tribunal Federal”) in 2012, judged by the Federal Supreme Court in 2012 when it was decided for the prevalence of the dignity of the pregnant women at the expense of life (survival) of the fetus. There are several species of malformation. Anencephaly makes the life of the fetus unfeasible, thereby granting the right of anticipation of his death. The bill reforming the Criminal Code treats the anencephalic abortion as a not punishable act ²⁰.

It is therefore necessary that the family be aware of what are the procedures that the child or adolescent is likely to be submitted to ensure the autonomy of family decision, providing the legal incapacity of the under age. In cases of humanitarian abortion where there is divergence between the decision of the under age mother and the legal representative (the pregnant woman wishing to abort and the legal representative not allowing and vice-versa), it is necessary to give priority to the life of the unborn. This situation, however, is quite debatable. The bottom line is that, first of all, the decision of the representative be established, in order to verify if they are really acting in the interest of the inapt or just following their own convictions.

According to Brandão and Heilborn ¹⁷, many patients wish secrecy about the information given in the consultation. However, when the adolescent informs pregnancy or the decision to perform abortion, the doctor should encourage them to tell their option to family and warn her about the risks to her health and her life in the case of abortion, as well as the legal implications under that act. It should be noted that protection of the confidentiality and health care are rights of patients seeking medical care after an abortion procedure.

In the event of abortion, the health professional cannot notify it to the police, court or public prosecutors. When it comes to such breach of confidentiality, the professional can be prosecuted ethically, as well as in civil and criminal courts. Note that the CEM 3, article 73, prohibits the physician to disclose fact that has com to their knowledge in the exercise of his profession, except for a just reason, legal duty or consent in writing of the patient. According to Article 74, the right to confidentiality also covers minors, being forbidden the disclosure of medical professional secrecy concerning them, including to the legal guardians, since the teenager is able to evaluate his/her problem and conduct themselves with autonomy .

Abortion was also discussed by Chaves and collaborators ¹⁸ in the cross-sectional study conducted in 2010 with 201 adolescents in incomplete abortion in a public maternity in the State of Alagoas. For teens who participated in the survey, abortion was a way of exercising autonomy, insofar as they counted on the right to have their clinical condition and identity preserved, health care and later family planning as an active form of the doctor to promote the well-being of these patients..

Taquette and collaborators ¹⁶, Taquette and collaborators, in turn, performed a study on ethical conflicts in assistance to adolescent health, based on interviews with professionals from Rio de Janeiro who reported 149 cases, identifying 250 situations that generate ethical conflicts experienced in health care of adolescents. The data referred to persons aged 12 to 20 years incomplete, attended in the Center for Studies of Adolescent Health at the State University of Rio de Janeiro (“Universidade Estadual do Rio de Janeiro” - UERJ). The authors explain that several conflicts were identified and to deal with them, it is not sufficient that health care professionals make use of codes and laws; They must consider, too, the bioethical reflection to stimulate joint debate.

The first conflict identified in the studies analyzed with regard to the issue of secrecy and confidentiality in the consultation. How to predict which adolescents can afford alone with the care of their health? It is recommended that these young people make decisions involving their parents. In the case of AIDS or illicit drug use, not locating the adolescent's family, it is necessary to have public resources that give social and emotional support to patients. Health professionals should not act in a paternalistic way, nor judge their patients through the eyes of their moral and religious views.

The second and third conflicts portray issues of mistreatment. In such cases, the provider is required to notify the suspicion to the Guardian Council, which will monitor, support, find solutions that do not invade other people's rights and do not increase the conflict ²¹. The second and third conflicts portray issues of mistreatment. In such cases, the provider is required to notify the suspicion to the Guardian Council, which will monitor, support, find solutions that do not invade other people's rights and do not increase the conflict 21. However, often the adolescent does not want to make a complaint for fear the abuser. Similarly, the victim's family does not complain, since the result will be the punishment of the abuser, which may involve disruption of family relationships ¹⁶.

So when there is violence in the reported circumstances, the professional is in face of a serious dilemma: if on the one hand, the complaint may aggravate the situation of a child or adolescent living with the aggressor, on the other hand, failure to report injures legal and ethical norms of professional practice. In the present case, it is difficult to define the most appropriate course of action, and careful consideration of the facts and, where applicable, reference to the ethics committee of the professional are recommended. Neglect and poverty-related abandonment must be recognized by health services, seeking equity in inequality in the resources offered by public policies.

In addition to the specific offenses in the Criminal Code and the Statute of the articles of the Child and Adolescent mentioned above, the Universal Declaration of Human Rights ²² guarantees the right to personal safety and humane treatment, in Articles 3 and 5, respectively. In addition, the Constitution of the Federative Republic of Brazil ⁶, in Article 1, section III, it brings the fundamental principle of human dignity. Therefore, it is clear that such violence infringes, in its entirety, the Brazilian legal system. Fundamental rights must be guaranteed especially in cases of extreme vulnerability. The duty of the health professional is undoubtedly to provide in relief, comfort and guidance in their scope of operation.

The fourth category of conflict concerns the practice of illicit activities such as abortion and drug use. Such situations should be evaluated carefully in order to prevent teens from suffering damage to their physical, psychological, moral, or any other nature. It is necessary that the health service has a channel of communication with the judiciary, so that effective measures are taken to enforce equity and social justice.

The fifth category of conflict relates to sexual activity before age of 14 19. Although sexual relationships are initiated increasingly early in the country, the Criminal Code describes this practice as the result of rape of the vulnerable, an offense under Article 217-A. Thus, the health professional should contextualize this youngster and with his clinical experience, evaluate each case. According to the wording of the Criminal Code, any lewd act or sexual intercourse with people under 14 configures sexual crime of rape against vulnerable. The rationale for criminalizing the conduct of having sex with children under 14 years is the lack of discernment of children and adolescents in this age about sexual activity. The legislator here understands that there is no maturity that provides the correct choice in sexual life to people that age. Since there is no discernment, people under 14 would be induced by the absolutely capable.

In the sixth category of conflict, responsibility for self-care of adolescents is called into question, because in the interpretation of civil law, these young people are relatively or absolutely incapable, with compromise of full autonomy. Thus, the decision on issues related to the health of this specific group must pass the scrutiny of parents or legal guardians. The professionals realize that patients from the age of 15 are generally able to exercise their autonomy to seek health care, such as counseling on contraception and prevention of teenage pregnancy.

A seventh category relates to health professionals. Disclosure of information recorded in medical records can cause irreparable damage to the teenager. It is necessary, therefore, that doctors, nurses and other professionals who may have access to the medical records of these patients act in accordance with the criteria of ethics, protecting secrecy and privacy, without forgetting the responsibility that they bear.

In the eighth category less frequent conflicts were included, among which the exploitation of adolescent labor, the lack of government resources for the purchase of necessary medicines to health care for this segment of the population and the inefficiency of the health system.

In 2010, Taquette ¹⁹conducted a study based on the themes generating conflicts experienced by the physician with attention to adolescent health. In addressing the issues surrounding medical care to adolescents, the author recommends that the consultation should have two phases: the first in the presence of legal guardians, and the second in their absence, guaranteeing the right to confidentiality and privacy of the patient.

Confidentiality and autonomy must be maintained when the health professional realizes that the information to be given to the patient about their health may cause her/him harm and that she/he is unable to cope alone with their decisions. The doctor will then inform them that the secrecy is broken, since the parents will participate in the decisions to be made. However, many families want to know everything that was said in the consultation so that, if this happens, it will be up the physician to talk with family members and try to convince them of the importance of maintaining patient privacy.

In this study it was observed that health professionals face difficulties in the health care of adolescents, since physicians should not lead the patient's history according to their values, but always do a self-reflection to be at the patient's service, not their own ²³. It is also necessary to know the ECA, to interact with hospital lawyers and prosecutors, and to maintain ongoing dialogue with the medical staff about the obstacles related to patients in this age group.

In the cross-sectional study, based on interviews with teenagers in incomplete abortion and undergoing curettage in the public maternity in Alagoas, conducted in 2010, Chaves and collaborators ¹⁸ sought to highlight the bioethical perspective. The research obtained the following results: the average age is 16.1 years; most are classified as mulatto, they did not use condoms and did not plan the pregnancy; Gestational age was 13.2 weeks on average. In addition, 81.56% of these adolescents provoked abortion, curettage being the most performed procedure. These data show that abortion in adolescents is a public health problem. The increase in the number of abortions was attributed to greater autonomy won by women after the advancement of feminist movements. The authors suggest that the decision about abortion in adolescence should be the patient's and the medical professional must promote sexual health, prevention of unwanted pregnancy and provide immediate assistance to women in abortion situations.

In 2002, Gonçalves and Ferreira ¹⁵ they presented a descriptive study based on the experience of reporting cases of violence experienced by adolescents by health professionals in family ambulatory clinic in Rio de Janeiro. The authors emphasized the need for health professionals to notify cases of mistreatment. Brazilian law requires that these professionals notify such events, under penalty of responding in court by omission of the fact. In the health professional's practice, such a situation is considered as a generator of conflict, as the notification requires the breach of professional secrecy, which is one of the basic principles of medical ethics. In addition to fear legal disturbance, they face some difficulties, such as family culture and threats by the aggressor, not counting the structural problems such as the lack of preparation of counselors and health professionals themselves to identify and deal with cases of ill-treatment²⁴, because this is a diversified matter, requiring profound knowledge.

The study of the series of cases by Brandão and Heilborn ¹⁷, including interviews with 13 middle-class adolescents in Rio de Janeiro, and with 12 family members, analyzes the phenomenon of pregnancy linked to youth individualization process. According to the authors, sexuality in adolescence conflicts with the interest of parents, because, for the former, this phase of the affective-sexual contacts is their freedom and autonomy, even under the parental roof, while for parents, this phase means to build their future through the studies. The children's sexuality entails rational learning, which requires negotiation rules, because it often brings the dilemmas involved and decisive issues such as whether to use contraceptives, how to use them, interrupting a premature pregnancy or not. According to the authors, such decisions also require interaction with the health professional, which, along with the family, will take the best decision, considering the limits of medical ethics and respecting the power of decision of adolescents.

Final Considerations

Considering the conflicts analyzed in the care of adolescent health from the perspective of ethics and bioethics, it is clear that the adolescent patient seeks confidentiality in medical consultations and the confidentiality of the information they provided. Therefore, it is recommended that the professional conduct this consultation on two occasions, one of them only with the patient and the other, with participation of the legal representative.

Moreover, if it were necessary to break the secrecy as ensures Article 74 of the CEM, the doctor should inform the prescription of this conduct in situations such as pregnancy, drug use, sexual abuse, violence and ill-treatment, of which the last three occurrences must be immediately communicated to the Guardian Council and the use of drugs should be conducted in the best way by the health care professional and the family, since hospitalization is often necessary.

To the Brazilian Civil Code, the adolescent under the age of 18 is relatively or absolutely incapable, and therefore requires the authorization of the legal representatives in cases of abortion with risk of death for pregnant woman. The dilemma is established when the legal representatives were negligent or abandoned this adolescent and, added to this, public policies are ineffective to effectively ensure human dignity, as established by the 1988 Federal Constitution of Brazil.

Confidentiality extends to information in medical records, which must be kept confidential, as the record is a document that belongs to the patient. Thus, for example, the identity of adolescents who aborted cannot be revealed, even this being defined as a criminal act, with penalties established in Articles 124 and 128 of the Penal Code. It is up to the courts to judge these cases, not the physician, whose chief duty is to ensure the right to health of the patient.

For adolescents, sexuality and its consequences are way to exercise autonomy. This exercise extends from the choice of contraceptive method to seeking consultations with gynecologists, general practitioners and family planning experts. Although, from a legal point of view, underage teenagers are considered relatively incapable, the choices of these patients are covered by many health professionals, as they perceive that, in practice, individuals from the age of 15 can already demonstrate competence for self-care.

Finally, the conflicts addressed here may cease to exist with the evolution of society, but probably other problems will emerge, since the issue of sexuality in adolescence is quite complex, encompassing physical and psychological aspects of teenagers, their health and intellectual and emotional maturity as well as social, cultural, educational, religious and economic characteristics of families. All these aspects mixed up in the tangle of normative and legal nuances exposed in the provisions of the Code of Medical Ethics, the Brazilian Civil Code, the Federal Constitution of Brazil and the Statute of Children and Adolescents, which are construed in accordance with the needs of a society in permanent change. Thus, this issue requires discernment, ethical reflection, and constant study form legal and health practitioners.

Referências

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• This study was produced within the Núcleo de Estudo e Pesquisa em Ética e Bioética, Escola Bahiana de Medicina e Saúde Pública, Salvador/BA, Brasil.

Publication Dates

• Publication in this collection
  May-Aug 2015

History

• Received
  28 Aug 2014
• Reviewed
  20 May 2015
• Accepted
  26 May 2015