In most cases, the law grants people autonomy over their own bodies, including a constitutional right to consent to or refuse medical treatment; however, for teenagers, that right is curbed by their parents, who have the right to control medical procedures in most cases until that child turns eighteen. There has been a lot of news lately where teens are fighting back against their parents over medical treatments, procedures, and even appointments. Read on to learn more about this issue, including mental health, substance abuse, and physical problems.
Parent – Child Medical Care
Traditionally when a teenager, child, or infant goes for medical treatment, including routine check-ups, parents are welcome in the room. Many doctors’ offices allow the parent in, while some do so only if the child says the parent can come in. This is especially true in more sensitive appointments. In most cases, a child’s parents or guardians are the ones who know the most about the child. As a result, parents are better situated than most others to understand the unique needs of their child and to make decisions that are in the child’s interests. Furthermore, since many medical decisions will also affect the child’s family, parents can factor family issues like time, strain, finances, and values into medical decisions about their children.
According to the University of Washington School of Medicine:
Parents have the responsibility and authority to make medical decisions on behalf of their children. This includes the right to refuse or discontinue treatments, even those that may be life-sustaining. However, parental decision-making should be guided by the best interests of the child. Decisions that are clearly not in a child’s best interest can and should be challenged.
The concern that a parent could make a decision that isn’t in their child’s best interest has led to some cases where children and teenagers start to fight back against their parents when it comes to medical care.
What are age of consent laws?
Doctors of all kinds, from dentists to ophthalmologists, have grappled for years with age of consent when it comes to mature adolescents. In a 2013 Pediatrics article, the authors stated:
It is well understood in the medical community that adolescents’ aptitude to make rational, responsible decisions changes over time and that older teenagers and young adults have substantially similar cognitive capacities.
This question of maturity, and the automatic assumption of parent’s rights, endures as the general background rule that will apply in the majority of court cases regarding treatment of teens. Most frequently, parents are “free to sort among alternatives and elect the course of treatment based on his or her assessment of the child’s best interests.” This rule applies to any patient below the age of majority, which is 18 in most states, although in a small number of states, such as Delaware (19), Mississippi (21), and Nebraska (19), it is higher. In Arkansas, Nevada, Ohio, Utah, and Wisconsin the age of majority varies due to high school graduation dates. Some health insurance plans also have rules associated with their policies.
Those who are evaluated to have a maturity over their physical age, however, have been deemed “mature minors” in some court cases. That concept, as psychologically valid as it is, is cloudier when it comes to state laws, which vary widely in their “mature minor” stances, including the ages at which one becomes a “mature minor.” SeverFew U.S. courts have already defined the term, and a few more will be tasked to evaluate it in coming months. Seventeen states do have some form of concession to the standard parental consent requirement, ranging from written exceptions from psychologists to emancipation rights. Most often, the exceptions are requested by minors seeking an abortion without parental consent or knowledge.
These rules have become increasingly open to exceptions aiming to protect minors’ privacy and bodily integrity, safeguard the public health, and respect older minors’ adult-like autonomy and decisionmaking ability.
Sensitive Categories of Treatment: Exceptions to the Rule
All states have created laws that mention some exceptions to the general rules of parental consent, thus allowing minors to consent to some specific types of medical treatment. These specific exceptions are justified primarily by the concern that minors will avoid seeking care for certain particularly sensitive conditions if they are legally required to involve their parents. For example, all fifty states and the District of Columbia do permit minors to get testing and treatment for sexually transmitted diseases or infections on their own. Some states–Texas and Utah–include HIV in the category of sexually transmitted diseases for purposes of testing, but not treatment, which would need parental permission.
In many states, but not all, minors can also give their personal consent without their parents’ input regarding reproductive health services, with regard to contraceptive services and prenatal care, as well as drug and alcohol abuse treatment and outpatient mental health services. Many of these laws limit the permission to minors over a certain specifically stated age, usually 12, 13, or 14. In addition, the ability of minors to consent to treatment for themselves does not necessarily mean that their parents lack the ability to require them to submit to treatment.
Abortion
Unsurprisingly, abortion is treated somewhat differently from other sensitive subjects. A majority of states–38 currently–have laws requiring parental consent for almost all minors seeking abortions, and several other states require parental notification. The Supreme Court has said a minor that is pregnant has a constitutional right to have an abortion without parental involvement if she is sufficiently mature or if it would be in her best interests mentally and physically. It includes a mental evaluation and a physical evaluation to determine whether or not the child could even carry a baby to term. “Tests of maturity can include questions about good grades or extracurricular activities, as well as other less-defined queries that would allow judges to see a young person’s thinking process and understanding of the procedure,” said Doriane Coleman, a law professor at Duke University. Some states allow another relative, such as a grandparent or aunt, to be present at the abortion; however, in states where parental notification or consent is required by the law, that constraint can be dodged if the minor goes to court and gets an order from a judge stating that she is legally allowed to consent to the abortion without involving her parents. This is rare, however.
Substance Abuse
When it comes to substance abuse and the following treatment patterns, including inpatient and outpatient rehabilitation, in some states the laws go half way to giving minors permission to make decisions about their bodies. They make it clear that minors can consent to treatment, but also that they cannot refuse consent for such treatment if it is authorized by their parents. This is consistent with the understanding that laws allowing minors to consent to treatment in this area are intended primarily to encourage them to seek such treatment, rather than to empower them to exercise decision-making autonomy. After all, a person who consents to treatment or requests treatment is more likely to follow through and at least stay in the program until the end.
For most doctors, the issue is that even if a minor is empowered by state law to give consent, they still need to ensure that the minor is intellectually and emotionally capable of giving informed consent, something that can be difficult, especially if the doctor doesn’t have a close relationship with the child. As such, even if there is no age limit under state law or the age limit is very low, at times doctors may find it is inappropriate to allow a specific minor to consent to his or her own care if he or she is too immature or otherwise incapable of understanding the procedure. They may still have to call in the parents.
Payment, Confidentiality, and HIPAA
The fact that some minors can consent to their own health care and treatments in certain areas does not always mean that they actually have a right to confidentiality with respect to that care. Under the Health Insurance Portability and Accountability Act (HIPAA), practitioners are basically required to follow state law regarding confidentiality for minors, and they are given discretion over parental notification when state law is silent on the issue. Most parents will find out eventually, whether it is from HIPAA or the patient’s own volition.
Special confidentiality rules also apply to particular federally funded programs. Services subsidized by Title X, the federal family planning funding program, are provided to both minors and adults confidentially in accordance with federal law. For minors covered by Medicaid, confidentiality in accessing family planning services is required. Because services provided under these programs must be provided confidentially, it follows that parental consent cannot be required.
Case Study: Cassandra C.
The Connecticut Supreme Court ruled recently that the state was well within its rights to require a young woman named Cassandra C. to continue undergoing chemotherapy treatments even though it wasn’t what she wanted. Her mother wanted her to do whatever she thought was best.
Because of the nature of the case, and concerns about Cassandra’s wellbeing, the case has been featured in the national news. Unfortunately, Cassandra spent every day in isolation from other patients and was under constant supervision. “She hasn’t been convicted of a crime, but it’s kind of like she’s in jail,” said Joshua Michtom, an assistant public defender and Cassandra’s lawyer. “It’s an especially lousy way to go through chemo.”
Court Orders
As seen above, there are some rare situations in which neither parents, other relatives, nor children can authorize a specific treatment. These are situations in which there is reason to doubt the usual presumption that the parents aren’t the best choices to act in the best interests of their children or when a particular case is extraordinary. A court order is required, for example, for sterilization of mentally incompetent children. In addition, there are cases like those outlined in the novel My Sister’s Keeper, where parents seek to have a minor child donate an organ to a sibling, or to undergo any other significantly invasive medical procedure for the benefit of another child.
Conclusion
Medical decision making by and on behalf of children and teens is a subject that is ethically, mentally, physically, and legally complex. State laws vary considerably, and they often have vague standards and language. Children should generally be involved in medical decision making to the extent of their abilities. It is not only a teaching moment, but it is also a way to create autonomy. In the case of a conflict between a minor’s wishes and a parent’s wishes, however, everyone needs to proceed with caution, especially in life or death cases. As such, it is usually wise for them to seek the advice of legal counsel and, in some cases, to proceed to court for a judicial order authorizing the proposed course of treatment.
Resources
Primary
District Court of Appeal of Florida, First District: DEPT. OF HEALTH v. STRAIGHT, INC.
Additional
Journal of Health Care Law and Policies: Medical Decision Making by and on Behalf of Adolescents
Guttmacher Institute: Minors and the Right to Consent to Health Care
Philly: Should Teens Get to Say “No” to Life-Saving Medical Treatment?
Pediatrics: The Legal Authority of Mature Minors to Consent to General Medical Treatment
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