Mature minor doctrine

The mature minor doctrine is a rule of law found in the United States and Canada accepting that an unemancipated minor patient may possess the maturity to choose or reject a particular health care treatment, sometimes without the knowledge or agreement of parents, and should be permitted to do so.[1] It is now generally considered a form of patients rights; formerly, the mature minor rule was largely seen as protecting health care providers from criminal and civil claims by parents of minors at least 15.[2]

Jurisdictions may codify an age of medical consent, accept the judgment of licensed providers regarding an individual minor, or accept a formal court decision following a request that a patient be designated a mature minor, or may rely on some combination. For example, patients at least 16 may be assumed to be mature minors for this purpose,[3] patients aged 13 to 15 may be designated so by licensed providers, and pre-teen patients may be so-designated after evaluation by an agency or court. The mature minor doctrine is sometimes connected with enforcing confidentiality of minor patients from their parents.[4]

Statute

In the United States, a typical statute lists: "Who may consent [or withhold consent for] surgical or medical treatment or procedures."

"...Any unemancipated minor of sufficient intelligence to understand and appreciate the consequences of the proposed surgical or medical treatment or procedures, for himself."[5][6]

Medical emancipation

By definition, a "mature minor" has been found to have the capacity to make serious medical decisions alone. By contrast, "medical emancipation" formally releases children from some parental involvement requirements but does not necessarily grant that decision making to children themselves. Pursuant to statute, several jurisdictions grant medical emancipation to a minor who has become pregnant or requires sexual-health services, thereby permitting medical treatment without parental consent and, often, confidentiality from parents. A limited guardianship may be appointed to make medical decisions for the medically emancipated minor and the minor may not be permitted to refuse or even choose treatment.[7]

History

One significant early U.S. case, Smith v. Seibly, 72 Wn.2d 16, 431 P.2d 719 (1967), before the Washington Supreme Court, establishes precedent on the mature minor doctrine. The plaintiff, Albert G. Smith, an 18-year-old married father, was suffering from myasthenia gravis, a progressive disease. Because of this, Smith expressed concern that his wife might become burdened in caring for him, for their existing child and possibly for additional children. On March 9, 1961, while still 18, Smith requested a vasectomy. His doctor required written consent, which Smith provided, and the surgery was performed. Later, after reaching Washington's statutory age of majority, then 21, the doctor was sued by Smith, who now claimed that he had been a minor and thus unable to grant surgical or medical consent. The Court rejected Smith's argument: "Thus, age, intelligence, maturity, training, experience, economic independence or lack thereof, general conduct as an adult and freedom from the control of parents are all factors to be considered in such a case [involving consent to surgery]."

The court further quoted another recently decided case, Grannum v. Berard, 70 Wn.2d 304, 307, 422 P.2d 812 (1967): "The mental capacity necessary to consent to a surgical operation is a question of fact to be determined from the circumstances of each individual case." The court explicitly stated that a minor may grant surgical consent even without formal emancipation.

Especially since the 1970s, older pediatric patients sought to make autonomous decisions regarding their own treatment, and sometimes sued successfully to do so.[8] The decades of accumulated evidence tended to demonstrate that children are capable of participating in medical decision-making in a meaningful way;[9][10] and legal and medical communities have demonstrated an increasing willingness to formally affirm decisions made by young people, even regarding life and death.[11]

Religious beliefs have repeatedly influenced a patient's decision to choose treatment or not. In a case in 1989 in Illinois, a 17 year old female Jehovah's Witness was permitted to refuse necessary life saving treatments.

In 1990, the United States Congress passed the Patient Self-Determination Act; even though key provisions apply only to patients over age 18,[12] the legislation advanced patient involvement in decision-making. The West Virginia Supreme Court, in Belcher v. Charleston Area Medical Center, 422 S.E.2d 827, 188 W.Va. 105 (1992), defined a "mature minor" exception to parental consent, according consideration to seven factors to be weighed regarding such a minor: age, ability, experience, education, exhibited judgment, conduct, and appreciation of relevant risks and consequences.[13]

Laws by jurisdiction

Canada

The Supreme Court of Canada recognized mature minor doctrine in 2009; in provinces and territories lacking relevant statutes, common law is presumed to be applied.[14]

Province or Territory	Minimum age	Notes
Alberta	None	The Child, Youth and Family Enhancement Act does not establish a minimum age. In practice, children at 16 are generally considered capable of consent to medical procedures; in some cases, the doctrine has been applied to children as young as 14.[15][16]
British Columbia	None	The Infants Act does not set an age at which a child becomes capable of consent to medical procedures, but the child must be capable of understanding the procedure and its risks in order to consent.[17]
Manitoba	None	It is presumed minors 16 and older can provide consent; minors 15 and younger and presumed to be incapable of consent but this can be rebutted.[16]
New Brunswick	None	Under the Medical Consent of Minors Act, minors 16 and older can consent to medical procedures. Minors under 16 can consent to treatment if they can demonstrate an understanding of the procedure and its consequences.[16]
Newfoundland and Labrador	None	The Advanced Health Care Directives Act presumes minors 16 and older are capable of consent to treatment.[16]
Northwest Territories	None	No statute exists in Northwest Territories dictating an age of consent; absent a statute, common law applies.[14]
Nova Scotia	None	Medical procedures can be performed on any person capable of providing informed consent.[16]
Nunavut	None	No statute exists in Nunavut dictating an age of consent.[16]
Ontario	None	The Health Care Consent Act allows all persons capable of informed consent to agree to treatment.[16] The Substitute Decisions Act presumes all persons 16 or older can give or withhold consent to care.[16]
Prince Edward Island	None	Medical procedures can be performed on any person capable of providing informed consent.[16]
Quebec	14	Minors 14 and older may consent to medical care but still require parental consent for optional procedures that involve significant risks, e.g. cosmetic surgery.[16]
Saskatchewan	None	Medical procedures can be performed on any person capable of providing informed consent.[16]
Yukon	None	Medical procedures can be performed on any person capable of providing informed consent.[16]

United States

Several states permit minors to legally consent to medical treatment without parental consent or over parental objections.[18] In addition, many other states allow minors to consent to medical procedures under a more limited set of circumstances. These include providing limited minor autonomy only in enumerated cases, such as blood donation, substance abuse, sexual and reproductive health (including abortion and sexually transmitted infections), or for emergency medical services. Many states also exempt specific groups of minors from parental consent, such as homeless youth, emancipated minors, minor parents, or married minors.[19] Further complicating matters is the interaction between state tort law, state contract law, and federal law, depending on if the clinic accepts federal funding under Title X or Medicaid.[19]

State	Minimum age	Notes
Alabama	14	Minors 14 years or older or who have graduated high school can consent to medical procedures.[19] No evaluation of maturity required.[18] Parental consent is required for abortion but can be bypassed.[19]^:18
Alaska	None	No evaluation of maturity required.[18] Parental consent is not required for abortion, as this violates the Constitution of Alaska's clause protecting privacy.[19]^:23
Arkansas	None	Any minors capable of informed consent.[18]
Delaware	None	"Reasonable efforts" must have first been made to secure parental consent.[18]
Idaho	None	Any minors capable of informed consent.[18]
Illinois	None	Any minors capable of informed consent, but refusal of medical treatment can be overruled.[18]
Kansas	16	Minors aged 16 are permitted de jure to consent to medical treatment when no parent is available. Mature minors are permitted to consent to medical treatment, but maturity must be assessed on a case-by-case basis.[18]
Louisiana	None	Minors are allowed to consent to any medical procedure they deem necessary.[18]
Maine	None	A mature minor's wishes expressed in a living will must be considered.[18]
Massachusetts	None	Mature minors meeting are permitted to consent to medical treatment, but only if their "best interests ... will be served by not notifying his or her parents of intended medical treatment."[18]
Montana	None	Any minors who have completed high school are able to consent to medical treatment.[18]
Nevada	None	Mature minors meeting are permitted to consent to medical treatment, but only if the healthcare worker believes the minor would risk a "serious health hazard" absent treatment.[18]
Oregon	15	Minors aged 15 and up have the authority to consent to (but not necessarily refuse) medical treatment.[18]
Pennsylvania	18	Minors aged 18 or who have completed high school can consent to medical treatment.[18]
South Carolina	16	Minors aged 16 and up can consent to any medical treatment other than "operations".[18]
Tennessee	7	Any mature minors capable of informed consent can consent to medical procedures. The courts make the rebuttable presumption that minors aged 7 to 13 are not mature, while minors 14 and up are.[18]
Washington	None	Mature minors may consent to medical procedures, including immunizations.[20]
West Virginia	None	Any minors capable of informed consent can consent to medical procedures.[18]

Withholding of consent

United States

In the United States, bodily integrity has long been considered a common law right; the United States Supreme Court, in 1891's Union Pacific Railway Company v. Botsford, found, "No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law." The Supreme Court in 1990 (Cruzan v. Director, Missouri Department of Health) allowed that "constitutionally protected liberty interest in refusing unwanted medical treatment may be inferred" in the Due Process Clause of the Fourteenth Amendment to the United States Constitution, but the Court refrained from explicitly establishing what would have been a newly enumerated right. Nevertheless, lower courts have increasingly held that competent patients have the right to refuse any treatment for themselves.[21]

In 1989, the Supreme Court of Illinois interpreted the Supreme Court of the United States to have already adopted major aspects of mature minor doctrine, concluding,

Although the United States Supreme Court has not broadened this constitutional right of minors beyond abortion cases, the [Illinois] appellate court found such an extension "inevitable." ...Nevertheless, the Supreme Court has not held that a constitutionally based right to refuse medical treatment exists, either for adults or minors. ...[U.S. Supreme Court] cases do show, however, that no "bright line" age restriction of 18 is tenable in restricting the rights of mature minors, [thus] mature minors may possess and exercise rights regarding medical care... If the evidence is clear and convincing that the minor is mature enough to appreciate the consequences of her actions, and that the minor is mature enough to exercise the judgment of an adult, then the mature minor doctrine affords her the common law right to consent to or refuse medical treatment [including life and death cases, with some considerations].[22]

An ongoing case of Z.M is being heard in Maryland regarding the minor's right to refuse chemotherapy.[23]

In Connecticut, Cassandra C. a seventeen year old was ordered by the Connecticut Supreme Court to receive treatment. The court decided that Cassandra was not mature enough to make medical decisions.[24]

Canada

In 2009, the Supreme Court of Canada ruling in A.C. v. Manitoba [2009] SCC 30 (CanLII) found that children may make life and death decisions about their medical treatment. In the majority opinion, Justice Rosalie Abella wrote:

"The result of this [decision] is that young people under 16 will have the right to demonstrate mature medical decisional capacity. ...If, after a careful analysis of the young person’s ability to exercise mature and independent judgment, the court is persuaded that the necessary level of maturity exists, the young person’s views ought to be respected."

A "dissenting"[25] opinion by Justice Ian Binnie would have gone further:

"At common law, proof of capacity entitles the “mature minor” to exercise personal autonomy in making medical treatment decisions free of parental or judicial control. ...[A] young person with capacity is entitled to make the treatment decision, not just to have ‘input’ into a judge’s consideration of what the judge believes to be the young person’s best interests."[26]

Analysts note that the Canadian decision merely requires that younger patients be permitted a hearing, and still allows a judge to "decide whether or not to order a medical procedure on an unwilling minor".[27]

See also

• Emancipation of minors
• Marion's Case (Australia)
• Gillick competence (UK)
• Age of consent
• Age of majority

References

1. West's encyclopedia of American law, Volume 8, West Publishing, 1998, page 47
2. Legal issues in pediatrics and adolescent medicine by Angela Roddey Holder, Yale University Press, 1985, page 133
3. "Definitions", USLegal.com, Retrieved 2011-05-16, "Mature minor doctrine is a legal principle which... has been consistently applied in cases where the minor is sixteen years or older"
4. The Mature Minor Rule: Teens and patient confidentiality, Public Health - Seattle & King County, Retrieved 2011-05-13
5. Mississippi Code, Retrieved 2011-05-13 Archived 2011-07-20 at the Wayback Machine
6. 2010 Arkansas Code, Retrieved 2011-05-13
7. Children and the Law by Douglas E. Abrams and Sarah H. Ramsey, West Group, 2003, page 769
8. "Affirming the Decisions Adolescents Make about Life and Death" by Robert F. Weir and Charles Peters, Hastings Center Report, Vol 27 No. 6, November–December 1997, Hastings Center, page 29
9. "Ethical problems in pediatric critical care: Consent" by Christine A. Zawistowski and Joel E. Frader, Critical Care Medicine, Vol 31 Issue 5, May 2003, page S407-S410
10. "Mature Minors Should Have the Right to Refuse Life-Sustaining Medical Treatment" by Melinda T. Derish and Kathleen Vanden Heuvel, The Journal of Law Medicine and Ethics, Vol 28 Issue 2, June 2000, pages 109-124
11. "Children's Competence to Participate in Healthcare Decisions" by Susan M. Beidler and Susan B. Dickey, JONA's Healthcare Law Ethics and Regulation, Vol 3 Issue 3, September 2001, page 80-87
12. The Patient Self-Determination Act: An Early Look at Implementation by Mathy Mezey and Beth Latimer, Hastings Center Report, January–February 1993, page 16
13. "Mature Minors and Emancipated Minors", Health Sciences Center, West Virginia University, Retrieved 2011-08-04 Archived 2011-12-26 at the Wayback Machine
14. Knight, Kimberly N. "Consent of Minors to Medical Treatment". Siskinds LLP. Retrieved March 29, 2019.
15. "Consent for Minor Patients – Advice to the Profession" (PDF). College of Physicians & Surgeons of Alberta. Retrieved March 29, 2019.
16. Coughlin, Kevin W. (April 12, 2018). "Medical decision-making in paediatrics: Infancy to adolescence". Paediatrics & Child Health. 23 (2): 138–146. doi:10.1093/pch/pxx127. Retrieved March 29, 2019.
17. "The Infants Act, Mature Minor Consent and Immunization". HealthLinkBC. December 2015. Retrieved March 29, 2019.
18. Coleman, Doriane Lambelet; Rosoff, Philip M. (April 2013). "The Legal Authority of Mature Minors to Consent to General Medical Treatment" (PDF). Pediatrics. 131 (4): 786–793. doi:10.1542/peds.2012-2470. PMID 23530175. S2CID 686006. Retrieved 12 March 2019.
19. English, Abigail; Bass, Lindsay; Boyle, Alison Dame; Eshragh, Felicia (January 2010). State Minor Consent Laws: A Summary, 3rd Edition (PDF) (Report). Center for Adolescent Health & the Law. Retrieved 12 March 2019.
20. "Providing Health Care to Minors under Washington Law: A summary of health care services that can be provided to minors without parental consent". Columbia Legal Services. November 5, 2007. Retrieved March 12, 2019.
21. "Towards the right to be killed?" by Trudo Lemmens, British Medical Bulletin, Vol 52 No. 2, British Council, 1996
22. In re E.G., 549 N.E.2d 322, 133 Ill. 2d 98, Supreme Court of Illinois, November 13, 1989, Retrieved 2011-05-16
23. "Court of Appeals Documents" (PDF). www.courts.state.md.us. October 3, 2016. Retrieved 2019-07-08.
24. "The Choice is Not Always Yours: A Minor's Right to Make Medical Decisions". Campbell Law Observer. Retrieved 2016-10-11.
25. That is, dissenting to the disposition of this specific case rather than the larger point of law
26. "A.C. v. Manitoba (Director of Child and Family Services)", Supreme Court of Canada, June 26, 2009, Docket 31955, Retrieved 2011-05-16
27. "Charter Offers No Protection from Forced Blood Transfusion for Young Jehovah’s Witness" by Jim Young, Center for Constitutional Studies, July 2, 2009, Retrieved 2011-05-16