Ethics in Sonography The ethical issues that are presented to us in this hypothetical ethical case study are all too likely to occur in real life as Australian teenage girls become pregnant all too often - and often have little understanding of the biology of pregnancy. The question of what a sonographer should do when faced with a 15-year-old girl who is pregnant no doubt happens with some regularity across the country. The question of what the sonographer should do in this case spans legal, ethical and medical issues, and this paper explores that range of issues.

The first consideration is the confidentiality that each patient is owed by her or her doctor as well as other medical staff. While the concept of patient confidentiality is meaningless in a very young patient (such as a toddler), it is by no means meaningless for a young woman of 15. The Australian Medical Association (as do other medical associations around the world) stresses the importance of this confidentiality:

Maintain your patient's confidentiality. Exceptions to this must be taken very seriously. They may include where there is a serious risk to the patient or another person, where required by law, where part of approved research, or where there are overwhelming societal interests (http://www.ama.com.au/web.nsf/doc/WEEN-5M4VJV).

This code applies primarily to doctors, but its tenets also apply to others who treat patients under the auspices of a physician, such as a sonographer. This is the single most important element of ethics that should guide the sonographer.

Exceptions to Confidentiality key question in this situation is whether the girls' pregnancy matches any of the conditions that either permit or allow the breaking of confidentiality between a health-care provider and an individual other than the patient. To answer whether this case qualifies is to some extent beyond our ability given the information with which we are provided in this test case.

For example, if the pregnancy is an ectopic one (i.e. A condition that is potentially life-threatening to the girl) then the sonographer has an obligation to notify the girl and her doctor right away. If the mother refuses to leave the room while the sonographer or the doctor tell the girl about the abnormal pregnancy or if the girl asks for her mother to be present when the sonographer or doctor discuss the results of the scan then in this case the mother should be informed along with the daughter.

However, if we assume that the pregnancy is a normal and healthy one and that the girl is not at any particular risk (beyond the routine risks of pregnancy) then the ethical question becomes slightly more problematic.

The sonographer should probably not inform the patient or her mother of the results of the scan but rather leave this to the doctor. This might be seen as simply "chickening out" and refusing to take responsibility, but in fact it is the physician's job to relay and to explain the results of all tests - from X-rays to MRIs to sonograms - to the patient. In this way, the physician (who has more medical training and a better sense of the patient's overall health) can provide a more accurate reading of the test than a sonographer could.

For example, the sonographer is unlikely to know if the girl has diabetes, which can significantly increase the risk that a female runs in pregnancy while a physician would in all likelihood know this about the girl.

Overwhelming Social Interest

There are a number of facts that the sonographer would have to determine before deciding whether there was an overwhelming social interest in telling the girl and/or her mother about the pregnancy. The key facts involve the way in which the girl became pregnant. Although the girl is under the age of consent in Australia, this fact has a different amount of weight in legal terms - even if only unofficially.

A criminal action is unlikely to be filed against a fifteen-year-old boy and girl for having consensual sex with each other. Such status crimes are relatively immune from prosecution. However, if the girl has been coerced into having sex by an older teacher, family member or family friend, then the issue becomes one of child abuse and the sonographer should alert child protection officials as well as the police - entirely aside from what the technician tells the girl and her mother.

If the girl has been raped, it is obviously a criminal matter and the police should be informed immediately.

If the girl has been molested or raped, the technician must be law report this fact, and the police are then free to tell the mother as they are under no limitation of medical confidentiality.

However, it is possible that the girl has become pregnant without engaging in intercourse:

For conception to occur, healthy sperm must be placed inside...

Withdrawal of the penis from the vagina before ejaculation of semen decreases the probability that sperm will enter into the vagina and travel up to the uterus, consequently causing fertilization of the egg.
The only way to get pregnant is if the sperm fertilizes the egg via the vagina, uterus, and finally the Fallopian tube. Therefore, any other form of sex without penetration is unlikely to cause conception. However, any sperm that may be in the general area of the vulva (exterior lips of the genitalia) may work its way into the interior during the course of sexual activity (http://www.womenshealth.org/a/pregnant_no_intercourse.htm).

If this has been the case and the girl was having consensual sex with another teenager then it is unlikely that any crime has occurred (since "consent" laws apply to intercourse and not to other forms of sexual behavior) and the sonographer is left facing an issue that has little if any compelling public policy element to it.

Of course (and this is an element of the therapeutic relationship that all health-care providers should work to establish with each one of their patients) the sonographer can and indeed should urge the girl to tell her mother about the pregnancy. Any 15-year-old facing decisions about a pregnancy should have the support of her family and the sonographer should talk to the patient about sharing her diagnosis. But the decision to share this information - barring a life-threatening situation or a suspected crime - must come from the girl.

The importance of teenagers' being able to seek confidential medical information is generally supported by medical associations around the world. This does not mean that medical professionals should not encourage their young patients to inform their families. But it acknowledges, especially in the arena of sexuality, that sometimes teens will only seek appropriate medical treatment when they can be assured of confidentiality:

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% said they would seek medical care for sexually transmitted diseases, drug abuse or birth control if they were forced to notify their parents (http://www.house.gov/judiciary/klei0527.htm).

It seems likely that if this girl were comfortably in talking to her mother about the possibility that she is pregnant, she would have done so already before this exam. This does not appear to be the case, making her typical of adolescents who are reluctant to discuss with their parents the fact that they are sexually active and especially the fact (for girls) that they are pregnant.

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…