Mature minor doctrine

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The mature minor doctrine is a statutory, regulatory, or common law policy 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 years of age.^[2]

Jurisdictions may codify an 'age of medical consent', may accept the judgment of licensed providers regarding an individual minor, or may 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 aged 16 may be assumed to be 'mature minors' for this purpose,^[3] patients aged 13 to 15 may be so-designated by licensed providers, and pre-teen patients may be so-designated after evaluation by an agency or court. The mature minor doctrine is sometimes, but not always, 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

See also: Emancipation of minors

By definition, a "mature minor" has been found to have the capacity to make serious medical decisions for herself. By contrast, "medical emancipation" formally releases the child from some parental involvement requirements but does not necessarily grant that decisionmaking to the child herself. 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 early U.S. case of significance, 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 age 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, noting in its ruling, "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 decisionmaking 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]

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 decisionmaking. 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]

Withholding of consent

See also: Informed refusal

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 that "[n]o 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 Constitutional right. Nevertheless, lower courts have increasingly held that a competent patient does have the right to refuse any treatment for himself.^[14]

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].^[15]

Canada

In 2009, the Supreme Court of Canada ruling in A.C. v. Manitoba found that children may make life and death decisions about their medical treatment; this annulled laws restricting capacity determinations to those aged 16 and older. 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"^[16] opinion by Justice Ian Binnie went even 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."^[17]

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".^[18]

See also

• Age of consent
• Age of majority
• Emancipation of minors

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
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
14. ^ "Towards the right to be killed?" by Trudo Lemmens, British Medical Bulletin, Vol 52 No. 2, British Council, 1996
15. ^ In re E.G., 549 N.E.2d 322, 133 Ill. 2d 98, Supreme Court of Illinois, November 13, 1989, Retrieved 2011-05-16
16. ^ That is, dissenting to the disposition of this specific case rather than the larger point of law
17. ^ "A.C. v. Manitoba (Director of Child and Family Services)", Supreme Court of Canada, June 26, 2009, Docket 31955, Retrieved 2011-05-16
18. ^ "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