Bioethical dilemmas in the medical care of pregnant teenagers

Abstract

The aim of this study is to identify and to discuss some bioethical aspects involved in medical assistance to pregnant teenagers. Through Integrative Review, it was selected two articles tackling the same chosen theme, contained in the Biblioteca Virtual em Saúde (Virtual Health Library) and published between 2010 and 2015. Based on researches, there was a significant decrease in the number of births among adolescents in the last five years. However, the indices are still worrying. As a result, it was found two alternatives in the relationship between doctor and pregnant teenagers: medical ethics and induced abortion, it having the autonomy and not-malfeasance as bioethical dilemmas. The Bioethics provides systematic reflections in the sense of involving the professionals of health and education in sexual and reproductive health and providing assistance tothe young woman, in which preventive measures of an unwanted pregnancy avoid the Incidence of unsafe abortion and, consequently, avoid them to look for clandestine services.

Adolescent; Bioethics; Pregnancy in adolescence; Consequence analysis; Women’s health

Resumo

Este estudo objetiva identificar e discutir dilemas bioéticos na assistência médica a gestantes adolescentes. Trata-se de revisão integrativa, a partir de artigos indexados na Biblioteca Virtual em Saúde entre 2010 e 2015. Foram selecionados dois artigos que abordam a temática. De acordo com os estudos, houve queda significativa no número de partos entre jovens nos últimos cinco anos. Contudo, os índices ainda são preocupantes. Em consequência disso, encontraram-se dois eventos na relação médico-gestante adolescente: ética médica e aborto induzido, constando a autonomia e a não maleficência como dilemas bioéticos. A bioética proporciona reflexões sistemáticas ao envolver profissionais de saúde e educação na promoção da saúde sexual e ao dar assistência imediata às adolescentes, incluindo medidas preventivas de gravidez indesejada, com o intuito de evitar incidência de aborto e submissão das jovens a serviços clandestinos.

Adolescente; Bioética; Gravidez na adolescência; Análise de consequências; Saúde da mulher

Resumen

Este estudio tiene como objetivo identificar y discutir algunos dilemas bioéticos en la asistencia médica a adolescentes embarazadas. Se trata de una revisión integradora, a partir de artículos indexados en la Biblioteca Virtual en Salud, entre los años 2010 y 2015. Se seleccionaron dos artículos que abordan esta temática. Según los estudios, hubo reducción significativa en el número de partos de las jóvenes en los últimos cinco años. Sin embargo, los niveles siguen siendo preocupantes. Como consecuencia de esto, se encontraron dos eventos en la relación entre el médico y las adolescentes embarazadas: ética médica y aborto inducido, considerando la autonomía y la no maleficencia como dilemas bioéticos. La bioética ofrece reflexiones sistemáticas al involucrar a los profesionales de la salud y de la educación en el fomento de la salud sexual y al proporcionar asistencia inmediata a las adolescentes, lo cual incluye medidas preventivas de un embarazo no deseado, con el objetivo de evitar la incidencia del aborto y la sumisión de las jóvenes a los servicios clandestinos.

Adolescente; Bioética; Embarazo en adolescencia; Análisis de las consecuencias; Salud de la mujer

According to the Estatuto da Criança e do Adolescente (ECA - Statute of the Child and Adolescent) ¹, adolescence is the period of human life between 12 and 18 years. The Brazilian population is estimated at more than 202 million, of which 8.43 million are female adolescents^2,3. It is assumed that one-third of women in this age group are in the gestational state. Pregnancy during this period, however, is considered inappropriate and of high risk for young women, as their body is still in the process of growth, making it difficult to bear and adequately protect the fetus ⁴.

Teenage pregnancy can be considered a public health problem, considering the number of pregnant women included in this profile and the high rates of complications such as maternal anemia, fetal distress during childbirth, cephalopelvic disproportion and lesions in the vaginal canal, as well as problems such as a potential increase in sexually transmitted infections (STIs) in this age group ^4-6. Some authors attribute this type of pregnancy to factors such as living with a partner, low income, early initiation of a sexual life, the influence of friends and family restructuring ^7,8.

Other authors ^9-12, however, do not recognize poverty as a condition of pregnancy in adolescence, assigning the problem to a combination of variables such as alcohol use and early sexual initiation. In any case, family support for adolescents is extremely important if young women are to understand the transformations they face and deal with biopsychosocial changes with maturity and awareness ¹³.

The term “bioethics” began to be used in recent decades through ethical discussions that sought to protect life and the nature of advances in biotechnology. The hegemonic perspective consolidated in this period focuses on areas of biological science and health, referring to four principles of the theory of principlism: autonomy, beneficence, non-maleficence and justice ¹⁴. Currently, this field uses a multidisciplinary approach and encompasses the social dimension, being defined as a study of human behavior in questions related to life and death.

In principlism, autonomy corresponds to the self-determination or self-government exercised by each person. Each individual, therefore, must be treated autonomously, as they have the right to make decisions about themselves. Beneficence refers to the duty to help others, promote or do good, maximizing benefits and minimizing risks. Non-maleficence is the opposite of beneficence, as some authors point out, and encompasses the obligation not to harm patients or put them at risk. Finally, justice corresponds to the formal principle of fairness, which determines fair, equitable and universal distribution of social duties and benefits ^14-16. Considering the bases of the theory of principlism, as well as the social morality regarding pregnancy in this age group, this study aims to identify and discuss bioethical dilemmas in the medical care provided to pregnant teenagers.

Method

An integrative descriptive review of literature was performed, based on the critical analysis and discussion of articles indexed in the Virtual Health Library (VHL) database and with keywords validated in Health Sciences Descriptors (DeCS): “Pregnancy in adolescence and bioethics”, “adolescent and bioethics” correlated with the Boolean operator “and”. The survey was conducted between March and September 2015.

An integrative review is a comprehensive method of research for literature reviews, as it allows the inclusion of studies with different methodological approaches in a systematic and orderly manner, facilitating the interpretation of a certain phenomenon. This methodological approach also combines information from theoretical and empirical literature ¹⁷.

The following inclusion criteria were used for the selection of articles: to have been published in Portuguese between 2010 and 2015; be free and full access; and contain reflections relevant to the purpose of the work. After applying the inclusion criteria, two articles ^8,18 in Portuguese were selected, as shown in Table 1. Despite the search for articles in internationally disseminated databases, a limited number of publications were found, illustrating the need for more studies on the subject.

Table 1
List of articles with authors and year of publication, title, conclusion and periodical. Jequié, Bahia, Brazil, 2015

n°	Author/year	Title	Conclusion	Journal
1	Silva JLP, Surita FGC (2012) 4	Pregnancy in adolescence; current situation	Pregnancy in adolescence is considered risky, inappropriate, dangerous and unsuitable for this age, especially since when it includes girls living in poor areas of less developed countries. Therefore, it is necessary to define plans and strategies to address the problem, regardless of the conflicts and controversies.	Revista Brasileira de Ginecologia e Obstetrícia
2	Santos NLAC, Costa MCO, Amaral MTR, Vieira GO, Bacelar EB, Almeida AHV (2014) 6	Pregnancy in adolescence: analysis of risk factors for low birth weight, prematurity and cesarean section	The results obtained in the study conclude that maternal variables (early age), absence of prenatal care and type of delivery can affect the health and vitality of the newborn. In this way, more investments in strategies are necessary to enable access and adherence of pregnant young people to specialized health services.	Ciência & Saúde Coletiva
3	Diniz E, Koller SH (2012) 7	Factors associated with pregnancy in Brazilian low-income adolescents	The study data show that many gestational adolescents are low-income, in contrast to other studies.	Revista Paidéia
4	Constantino CF (2010) 8	Emergency contraception and adolescence: responsibility and ethics	Unwanted pregnancy has been improperly resolved, with abortions and forced marriages, disregarding dialogue and speeding up decision-making that can undermine the adolescent’s life. Finally, sex education should educate on commitment and responsibility, acting as a tool for adolescents of both sexes to be more careful in their choices.	Revista Bioética
5	Chaves JHB, Pessini L, Bezerra AFS, Rego G, Nunes N (2010) 18	Abortion provoked in adolescence from a bioethical perspective	Urgency is recommended in strategic family planning programs and in the anatomopathological examination of material from abortion. Proactive bioethical reflection becomes an instrument to provide minimum guidelines of protection and assistance to adolescents, and assistance to the health professional.	Revista Brasileira de Saúde Materno Infantil
6	Moreira RM, Teixeira SCR, Teixeira JRB, Camargo Cl, Boery RNSO (2013) 19	Adolescence and sexuality: a bioethical approach	Adolescent care breaks the limits of medical research and includes ethical, bioethical, legal, psychic and sexual counseling aspects, involving a holistic approach to a developing being, in which privacy and confidentiality favor the preventive approach and the denunciation of ill- treatment, sexual abuse, neglect and violence.	Revista Adolescência & Saúde
7	Taquette SR, Vilhena MM, Silva MM, Vale MP (2005) 20	Ethical conflicts in adolescent health care	The ethical conflicts in the care of adolescents are constant and to solve them bioethics presents itself as a useful instrument. In addition, it is necessary to understand laws and codes, consult the competent bodies and assess particular situations, not following absolute requirements.	Cadernos de Saúde Pública
8	Taquette SR (2010) 21	Ethical conduct in adolescent health care	For a bioethical approach, it is necessary to clarify the problem within the agenda, its assumptions, actors and type of conflict, analyze the situation based on ethical references and formulations of the problem (legal, deontological, moral norms, guidelines and resolutions) and lastly, choose ethical actions, respecting prima facie principles and laws. The professional, however, cannot forget that their behavior is always observed and that they are expected to make a greater effort to solve problems.	Revista Adolescência e Saúde
9	Oselka G, Troster EJ (2000) 22	Ethical aspects of adolescent medical care	The physician involved in the practice of adolescent medicine (hebiatrics) must be concerned with the peculiar ethical dimensions of the physician-patient relationship in this period of life. The peculiarities inherent in the medical care of adolescents are increasingly recognized and duly valued. Doctors - even those who often provide care to adolescents - sometimes face ethical dilemmas that are difficult to resolve. The recommendations of the Society of Pediatrics of São Paulo and of the Brazilian Society of Pediatrics will certainly assist physicians in these delicate situations.	Revista da Associação Médica Brasileira
10	Reddy DM, Fleming R, Swain C (2002) 23	Effect of mandatory parental notification on adolescent girls’ use of sexual health care services	Compulsory notification of parents for the use of prescribed contraceptives would prevent girls from joining sexual health care services, contributing to the potential increase in adolescent pregnancies, and the spread of Sexually Transmitted Infections.	Jama
11	Risi EE (2012) 24	The scale of abortion in Brazil: trends and estimates between 2000 and 2010	The analysis showed that the number of hospitalizations per abortion in the Brazilian National Health Service is declining, with the majority being young black or brown women. A reduction in estimates of the number of induced abortions has also been observed, especially among young women up to 29 years of age. Despite the small reduction in the induced abortion rate, the incidence of abortion is very high for a country where contraceptive use is so widespread, indicating the need for better access to available resources and methods. Estimates suggest that abortion still plays a significant role in controlling fertility in the country, requiring public debate on reformulation of laws and access to legal abortion in Brazil.	[Dissertation]
12	Almeida RA, Lins L, Rocha ML (2015) 25	Ethical and bioethical dilemmas in adolescent health care.	The study involves patients with very broad age ranges and with particularities resulting from the transition phase between not being a child and not yet reaching adulthood. Such specificities require not only different medical specialties and other health areas, but also the knowledge of the ethical, bioethical and legal aspects involved in the health care of these patients.	Revista bioética
13	Angelim RCM, Costa DA, Freitas CMSM, Abrão FMS (2015) 26	Induced abortion: brief reflections from the principlist bioethical perspective	When considering medical consultations with pregnant women at abortion clinics in the United States, it can be concluded that the principles of bioethics are not properly respected, and there is a need to provide further clarification on the rights and duties of these women and to offer qualified assistance based on efficiency, effectiveness and effectiveness.	Revista Enfermagem Digital Cuidado e Promoção da Saúde

Due to the relevance of the study objective, the decision was taken to include other studies ^4,6,7,19-26 which, although addressing the theme, were not indexed with the reported descriptors. Six further articles were therefore discussed.

In order to develop this study, the following steps were adopted: choice of theme; delimitation of the problem; critical reading and data discussion; results and conclusion. Immediately after reading, two topics were delineated: induced abortions and medical ethics in the doctor-pregnant teenager relationship.

Results and discussion

Incidence of pregnancy in adolescents

Globally, around 16 million girls between the ages of 15 and 19 and one million children under the age of 15 give birth every year, most of whom live in underdeveloped or developing countries ⁶. In Brazil, the pregnancy rate among adolescents has fallen significantly in the first years of this decade. There was a decline from 20.9% in 2011 to 17.7% in 2013, although the ideal target is below 10%. The north and northeast regions of the country had the highest percentages in 2011, with 22.9% and 20.1%, respectively ²⁷.

Researchers consider that the reduction in the number of pregnant women in this age group results from improved education and greater opportunities in the labor market. A study by the Brazilian Institute of Geography and Statistics (IBGE) confirms this hypothesis, revealing that the reduction in pregnancy in adolescence is a consequence of economic growth and greater employment opportunities ^8,27.

Considering the increase in health education policies aimed at guiding young women in family planning, the national percentage of women who became pregnant between the ages of 30 and 34 increased from 14.4% in 2001 to 18.3% in 2011. These data reinforce the data mentioned. In the south and southeast of Brazil, the percentage of women who had children in this age group is even higher: 19.9% and 20.7%, respectively, which makes it possible to relate pregnancy to schooling, income, employment and the age of pregnant women ²⁷.

Medical ethics

Article 74 of the Código de Ética Médica (CEM - Code of Medical Ethics) states that it is forbidden for doctors to breach the confidentiality of adolescent patients, even to their parents or legal guardians, as long as the child demonstrates the ability to understand and solve their problems^20,28. Based on the code, it can be guaranteed that privacy is a guaranteed right, and that minor should be seen by doctors alone, without the presence of parents, if they prefer. This guarantee is established by the confirmation of their legal responsibility, the ability to make decisions about their bodies and the recognition of their individuality.

However, cases in which the adolescent wishes to be accompanied by family members, when they exhibit intellectual disabilities or psychiatric problems, among others, should be considered as exception criteria. In such situations, a breach of confidentiality is required. In such cases, another health professional should be present at the medical clinic, accompanying the adolescent, in order to safeguard the doctor, neutralizing any potential accusation on the part of relatives ^7,21,22.

Research in the USA has shown that adolescents do not disclose some information when they are denied confidentiality and autonomy²³. This situation, which breaks the bond of trust, may interfere in the treatment or continuity of the doctor-adolescent relationship, as, primarily, there is a break in human relations ¹⁹. When the professional realizes that he/she needs to breach confidentiality, the adolescent must be informed in advance. The justifications for this decision should be discussed and weighed with the young person so that they understand the legal reasons that determine such an act. The diagnosis of HIV positive serology is an example, where the patient should be advised of the importance of treatment during pregnancy to avoid transmission to the baby ^6-8,22.

Also regarding this issue, there are conflicts between the professional conduct of recording patient information in medical records and the beneficence of maintaining confidentiality about this information. This is due to the easy access of parents and health service professionals to medical records. Consequently, most professionals omit some data and tests to maximize benefits and minimize losses to the adolescent ²³.

Induced abortion: public health or life-threatening?

Abortion is defined as the end of gestation before the twenty-second week, with the fetus weighing less than five hundred grams, by expulsion or extraction of the conceptual product before its viability ²⁴.

Unsafe abortion is one of the major problems involved in women’s health, generating numerous sexual and reproductive consequences. Over the years, the rate of induced abortion has been significantly reduced. Yet it is still considered high, with hospitalization caused by inappropriate procedures the main consequence, compromising the physical and psychological health of the adolescent ^18,25.

Between 2000 and 2010, approximately 2.5 million post-abortion curettage and manual intrauterine aspiration procedures were recorded in Brazil, as reported in Table 1. This method consists of removing placental remnants from the uterine cavity. Analyzing the data in the table, the reduction is clear, also indicating a decrease in the number of abortions ²⁴.

Table 1
Distribution of hospitalizations related to post-abortion curettage and manual intrauterine aspiration procedures, by year of hospitalization in Brazil, between 2000 and 2010

Year of Hospitalization	Post-abortion curettage	%	Manual intrauterine aspiration	%	Total
2000	235,202	100	----	---	235,202
2001	233,967	100	202	0	234,169
2002	232,374	99	3,189	1	235,563
2003	231,217	98	3,798	2	235,015
2004	239,639	98	4,493	2	244,132
2005	235,749	98	4,961	2	240,71
2006	215,554	96	8,062	4	223,616
2007	209,322	96	8,804	4	218,126
2008	195,519	96	8,203	4	203,722
2009	196,398	95	10,276	5	206,674
2010	192,489	95	10,420	5	202,909
Total	2,417,430	97	62,408	3	2,479,838

• Source: SUS Hospital Information System (MS/Datasus), SIH-SUS 2000, 2010.

Many abortions are performed in a clandestine or dangerous manner, such as by the ingestion of chemicals or even the introduction of such substances into the vaginal canal, putting the health of the adolescent at risk. The International Federation of Gynecology and Obstetrics (Figo) defends the bioethical principle of the right of women to autonomy, supporting access to safe abortions, without ethnic or social discrimination, among other issues. As an integral part of this guarantee, Figo also states that governments and authorities must make serious efforts to ensure this right by developing educational activities to prevent unwanted pregnancies. Added to this is the guideline for contraception, when desired, as discontinuation of pregnancy is not a contraceptive method ¹⁸.

In adolescence, there is a significant incidence of conflictive situations in which established norms prove insufficient to respond to ethical issues with clarity. The aspects concerning these dilemmas in the practice of abortion in adolescents are affected by various conflicts, ranging from the medical to the religious community. The ethical principles in the care of adolescents in health services refer especially to privacy, confidentiality, secrecy and autonomy, as abortion of adolescents is an ethical public health problem ^4,20.

It is therefore necessary to work in several sectors of health, especially primary health care, which must act together with society in the promotion, prevention and rehabilitation of health. Thus, among the rights and duties of every individual, the right to sexual and reproductive health must be guaranteed, including through the provision of family planning to prevent unwanted pregnancies. However, due to the number of unplanned pregnancies, the deficiency in planning is clear ²⁵.

It is emphasized that, in case of hospitalization for abortion, the adolescent has the right to the protection of confidentiality and health care. The accompanying medical professional cannot notify the police, judicial or prosecutorial authorities. By keeping the information confidential, the doctor exercises beneficence, one of the pillars of bioethics and, consequently, minimizes risks ^18,23-26.

Considerations on bioethical dilemmas

Based on the results presented, the rate of adolescent pregnancies remains high. Various analyzes can be made in the light of bioethical principles and concepts, especially considering the beneficence, non-maleficence and autonomy of the adolescent in relation to their sexual and reproductive life. These issues should be weighed and tackled by health professionals and managers in an ethical manner, considering that young women often suffer interpersonal violence from their own family. This situation, still common in several regions of the country, is only a small part of the secondary problems that can affect young women.

The primary dilemmas are of a psychological and biological nature, with induced abortion being one of the main factors of psychological conflict. Pregnancy in this age group severely modifies the body and affects interpersonal relationships in the different social nuclei of the adolescent, such as family, school environment, work and friends. The woman’s own body is unprepared for pregnancy, which can expose the mother and child to risks.

Bioethics, therefore, reflects on the importance of the involvement of health professionals in education and training processes related to the theme, aimed at the well-being of young women. Preventive measures, such as the distribution of condoms and health education, should protect them further, ensuring the full realization of their sexual and reproductive rights. In addition, these measures should be improved, especially in primary care, as a way of promoting health. Finally, and following the bioethical principle of non-maleficence, these initiatives should reduce the incidence of abortion and prevent young women from putting their lives at risk by undergoing clandestine services.

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Publication Dates

• Publication in this collection
  Jan-Apr 2018

History

• Received
  5 May 2016
• Reviewed
  12 Sept 2017
• Accepted
  14 Sept 2017