Decision-making for Minors

by Mark Hughes, MD, MA

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    00:01 So it may also be the case that we need to make decisions for minors.

    00:05 So minors are generally considered children less than the age of 18.

    00:10 It's going to depend on the jurisdiction about how this is defined.

    00:13 But in that case, we're you're generally assuming that that child cannot make decisions on their own.

    00:19 They don't have the capacity to make decisions.

    00:22 And generally we're going to rely on parents to be the authority to make decisions on their behalf.

    00:27 They have the responsibility to make decisions for the minor.

    00:32 It is the case the parents can factor in family issues or family values into the decision they might make for their particular child, when they're going through the informed consent process.

    00:43 But there may be circumstances where that parental decision can be challenged.

    00:49 So if the clinicians feel that the decision by the parent is potentially dangerous to the child's health.

    00:55 They might say, "No, we don't accept your decision.

    00:59 We want to have more discussion about this." Classic example might be a child with leukemia.

    01:05 Chemotherapy is recommended, has a high chance of success.

    01:09 And the parents are saying no to the chemotherapy.

    01:12 There you think is potentially dangerous to the child's health.

    01:15 Here's an effective treatment that has a high success rate, You really think that they should have the chemotherapy, That parental decision to say no to the treatment of the chemotherapy can be challenged.

    01:27 There may be times when you think the parental decision is imprudent or neglectful.

    01:32 So a parent making decision to use alternative medicine practices, rather than a tried and true established effective medical treatment for their child.

    01:43 Again, the clinicians can challenge that decision by the parents.

    01:47 If it's outright abusive, if either there's neglect of the child in the home situation, or the parents were actually abusive to the child, there may be additional reporting requirements to the health department, to state authorities, Child Protective Services, to report that separate from any kind of medical decisions that the parents might make.

    02:10 And maybe the court would decide that the parents can't make decisions on behalf of the child, if there has been abuse or neglect.

    02:19 Now, if there are no parents, if there is no parental involvement, the child is estranged from their parents or their parents are deceased, then when you do need to find an authorized decision maker for the child.

    02:31 That might mean that you go to the court to get a guardianship, and then the guardian will make medical decisions on behalf of the minor.

    02:38 There was also the case that there may be minors, so those that are under the age of 18, that are treated as adults.

    02:45 So they're called emancipated minors.

    02:47 They have the same authority as an adult to make their own treatment decisions.

    02:51 Again, this is going to depend on the jurisdiction where you practice.

    02:54 So you have to check on that.

    02:57 But often, the list of things that would qualify as being an emancipated minor would be the minor gets married, they have a child of their own, so they become a parent. That makes them emancipated.

    03:10 They join the military, again, that depends on the jurisdiction, or they've demonstrated that they are financially independent and living apart from their parents.

    03:21 They've shown to the court that they are independent, and therefore the court has deemed them as emancipated.

    03:31 There's also the case that there may be conditions that are treated for minors were for those actual conditions or those treatments they are considered what's known as statutory adults.

    03:46 So they can make decisions about these conditions or these treatments, even in all other respects they're considered minors, and need someone else to make decisions for them.

    03:56 Again, check your jurisdiction about how this applies.

    04:01 So what are the possible options for where this might happen? So it could be for treatment or advice for substance use disorder, the miner might be able to seek treatment on their own and consent to treatment without any kind of parental involvement.

    04:18 It may be for mental health services, it may be for reproductive health issues, which could range from contraception, to sexually transmitted diseases to pregnancy, all of those times for reproductive health issues, that the minor might be able to make treatment decisions on their own.

    04:38 One that's been recently controversial is whether minors could consent to vaccinations.

    04:44 So in the COVID pandemic, there are some jurisdictions that would only allow parents to make decisions for a COVID vaccine on behalf of their child, but in other places the minor could consent on their own.

    04:58 So open to debate, I think it's an important enough issue that maybe this should be something to consider as we're patient or a minor is considered a statutory adult.

    05:09 But check your jurisdiction.

    05:13 Alright, why would we allow this to happen for these conditions in particular? Well, they do involve some element of confidentiality.

    05:22 So we want to have adolescents seek care and be forthcoming about their health concerns.

    05:28 If they didn't have this possibility, if they were concerned about their parents learning what's going on, maybe they wouldn't be so forthright about what's happening with their health, or if they they're having symptoms and so on.

    05:41 So this is a means of them getting the care that they need, while maintaining confidentiality.

    05:48 And maybe the case that patients who need help care, if they are not considered statutory adults, they'll not receive the care they need.

    06:00 And that's going to be negative consequence for themselves.

    06:05 They're not getting their substance use disorder treated, they're not having their depression treated.

    06:10 All of these things might have bad consequences for them, but also as a public health issue, bad for the community if these adolescents didn't have the care provided to them.

    06:24 So when might you consider or things that you need to consider for statutory adults.

    06:29 So there are a few factors that you have to take into account.

    06:33 First of all, what's the patient's chronological age? So a 12-year-old making decisions compared to a 16-year-old, there may be differences in their ability to process information and understand it to make decisions.

    06:49 You might need to take into account their maturity.

    06:52 So what is their cognitive and psychosocial development, in terms sort of understanding their condition, and taking the treatment that you're recommending.

    07:06 You want to make sure that there's been no abuse or exploitation of the minor.

    07:11 So you need to sort of understand the circumstances of why they're seeking care for the condition.

    07:16 If there are concerns about abuse or exploitation, you may need additional safeguards put in place for them.

    07:25 If you are taking care of a patient over time, how do you see them handling other health behaviors? Have they been keeping their appointments? Do they take medications for conditions other than these ones that we've mentioned.

    07:41 So is that sort of a demonstration that they are mature enough to be able to handle taking care of the condition themselves.

    07:49 It's also important, in pediatrics, especially, the therapeutic relationship is really tripartite.

    07:56 It's the child, the parent, or guardian, and the clinician.

    08:02 So all three generally working together.

    08:04 So you want to know, what's been the involvement of the parent or the guardian.

    08:09 What have been the prior communications within the family? Is this something that you really try to encourage this minor to share with their parent, because you think it's important for them as a family unit to handle this condition together? If you really have concerns about parental involvement, then this might be an instance where you would consider them statutory adults and being able to make their own decisions.

    08:35 So these are additional considerations when you are getting consent as statutory adults.

    08:41 So one, as I said, you might want to try to persuade them that maybe it's a good idea to talk to your parents or your guardian.

    08:48 That you're seeking this advice or this treatment.

    08:51 Would it be okay with you minor for me to ask these questions or inform your parents, this is what you're going through.

    09:01 Again, they can say yes or no to that.

    09:06 What's going to be the outcome, if they don't get the care they need? Are they going to have any sort of serious mental health or other concerns? where that's going to really put them in jeopardy? So how important is it of an issue that you really need to get them to treatment? If you think it's important, it's really going to be in their best interests, and it should be done without the parents consent, then you can proceed.

    09:33 And, again, some of this is going to depend on the particular minor have they understood the advice being given? Do they understand the advantages, the disadvantages, the potential long term impact? All the things that we would normally do in a consent process? Are they able to process that information and say, "Yeah, this is going to be best for me." And part of that is also checking their understanding.

    09:57 Can they give a rationale around their reasoning, in their decision making? So, sort of demonstration that they've given that expressed consent?

    About the Lecture

    The lecture Decision-making for Minors by Mark Hughes, MD, MA is from the course Informed Consent and Capacity.

    Included Quiz Questions

    1. A minor who is self-supporting and independent of parental control
    2. A minor who is supported by their parents
    3. A minor living with their parents and attending high school
    4. A minor who is self-supporting and depends on parental control
    5. A child under the age of 10
    1. Military member
    2. After-school camp counselor
    3. Free-willed child
    4. Teenager who owns a car
    5. Minor league baseball player
    1. Treatment for substance use disorder
    2. Treatment for hypercholesterolemia
    3. Treatment for obesity
    4. Treatment for an upper respiratory infection
    5. Treatment for wisdom tooth extraction
    1. Minor's chronological age
    2. Minor's social circle
    3. Minor's favorite activities
    4. Minor's attitude toward social media
    5. Minor's daily routine

    Author of lecture Decision-making for Minors

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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