In response to Washington, DC’s newly passed law allowing minors to consent for vaccines, even over parents’ religious objections, some have sued.1 The well-publicized lawsuit centers on a timely topic, but the conflict over adolescent consent is nothing new. “The COVID vaccine is just bringing this issue to the surface. It is a long-standing issue in pediatric medical ethics,” says Kyle Brothers, MD, PhD FAAP, a member of the American Academy of Pediatrics’ section on bioethics executive committee and an associate professor in University of Louisville’s department of pediatrics.

Parental rights issues often are asserted, but at the same time, society has a stake in protecting children from harm, including medical neglect. “Parental rights are important, but there are limits,” says Gregory D. Zimet, PhD, HSPP, a clinical psychologist and professor at Indiana University’s department of pediatrics.

Adolescent children also have rights to make certain decisions about their health. “COVID-19 vaccination has, unfortunately, become a high-profile, divisive issue, which is probably why the issue of adolescent consent has been so prominent,” Zimet says.

“The question in terms of giving adolescents the ability to consent to their own COVID-19 vaccine, or any other vaccine, is: Is there a good reason to break from the law’s defaults?” Brothers asks. “There are already exceptions.”

State laws allow adolescents to make healthcare decisions for services they probably would not seek without confidentiality (e.g., substance abuse, STIs, and birth control). Emancipated minors have the legal rights of adults in terms of medical decision-making. Some states have enacted a “mature minor” doctrine, allowing minors to consent if they are deemed sufficiently mature to understand the risks and benefits of treatment. “The fundamental idea is children don’t have their 18th birthday and suddenly change in terms of their ability to make decisions. The law has only imperfect solutions for respecting that continuous process of development,” Brothers observes.

Brothers says a strong ethical case could be made for a blanket policy for adolescents to consent to any approved vaccine without parental consent. “It’s clear that older adolescents, and maybe even younger adolescents, are frequently mature enough to make a decision like this,” Brothers offers.

Even before the COVID-19 pandemic, there were problematic cases. Some adolescents needed vaccination to attend college, for instance, but parents were not available or refused to consent. “We do see situations where parents and kids are not on the same page,” Brothers reports.

In those cases, says Brothers, pediatricians use a shared decision-making approach. Even if the vaccine disagreement is not resolved during the office visit, it is a chance for pediatricians to model good medical decision-making. “It’s part of the role of parents, and also pediatricians, not just to give children the best possible medical care, but also to prepare them to make decisions as they get older,” Brothers says.

If parents still will not consent to vaccines, though, adolescents can circumvent this only if they are emancipated minors, turn 18, or take the rare step of obtaining a court order. “We do have kids in difficult situations where they are trying to get medical care, but the people who have the right to make decisions [on their behalf] are not available or willing. There is not a great solution for this under the law,” Brothers laments.

Adolescents do have the capacity to make a thoughtful, informed decision about vaccinations, according to Zimet. “It would be great if policymakers used this moment to consider allowing minor adolescents to consent to vaccination. However, I do not have a lot of confidence in this happening,” he says.

Zimet says it is ethical for adolescents to decide to vaccinate themselves against a clear health threat, such as COVID-19 or HPV. “Healthcare providers are certainly faced with a dilemma when an adolescent directly asks for the vaccine when parents do not consent,” Zimet says. “However, I think this dilemma is a legal and logistical one, not an ethical one.”

In fact, Zimet argues it is ethically questionable if a parent denies COVID-19 vaccination when the adolescent wants the shot. “An argument could be made that the parent’s behavior in this circumstance is unethical, comparable to medical neglect,” Zimet says.

Parents usually are the best advocates and prioritize the teen’s interest, says Dorit Rubinstein Reiss, PhD, professor of law at UC Hastings College of the Law in San Francisco. “But parental rights are not absolute and do not always match the teen’s interests. At the end of the day, parents have a duty to the teen and are trustees, not owners,” she says.

Since the risks of COVID-19 vaccines are small in general, and are smaller than the risk of not vaccinating, “there are good grounds to let teens get access to vaccines without parental consent,” Reiss says.

Older children, and especially adolescents, often are capable of ethically valid informed consent, says Mark C. Navin, PhD, HEC-C, a clinical ethicist at Beaumont Health and chair of philosophy at Oakland University in Michigan. That counts in favor of allowing such children to choose to be vaccinated. “However, parents also have moral responsibilities to make good choices for children,” Navin notes. “Since vaccination is almost always in a child’s interests, the moral case for parental refusal of vaccines for their children is not good.”

Physicians should bear in mind their primary responsibility is to their patient, says Georges C. Benjamin, MD, executive director of the American Public Health Association. State laws concerning the age of maturity for decision-making and particular situations (e.g., emancipated minors, homelessness, minors who are not living with their parents, or married minors) also are considerations. “There are also situations where engaging the parents becomes a real challenge because it’s not in the child’s best interest,” Benjamin says.

In cases of abuse or domestic violence, providers often work with local authorities to override parental consent requirements. “The other thing is that you can have a conflict where the child’s best interest collides with the parent’s views,” Benjamin reports.

In extreme cases, providers can secure a court order to override parents’ decisions. “These are generally not things that happen each and every day. What happens much more frequently is that the adolescent wants to get their care confidentially,” Benjamin explains.

This often happens with treatment for STIs or substance abuse, but it also could happen with vaccinations. “In those situations, the physician has an obligation to try to reconcile that situation the best that they can,” Benjamin says.

The physician must maintain the trust between the child and parents and not undermine it, to the extent possible. “It’s important that the physician evaluates the request and the context for that request,” Benjamin stresses.

The physician should try to learn why the child is reluctant to engage their parents and correct misconceptions. Even if the state has carved out certain healthcare services that do not require parental consent, that does not mean parents will not find out about it through insurance claims or medical records. “If the child is uncomfortable talking to their parents but has not really thought it through, physicians can let them know that parents can find out about these things,” Benjamin suggests.

This can be a jumping-off point to encourage the child to allow the provider to engage their parents in the situation. The issue of potential harm to others has to be factored in, too. If it is a live vaccine at issue, and a family member is immunocompromised, the child taking the vaccine could harm that family member. “Or, one could argue, in the case of COVID, that not vaccinating their child could put somebody else at risk,” Benjamin offers.

Some parents are vaccinated themselves but weigh the risk/benefit analysis differently for their children. “They are not quite sure of the long-term risks for their children and they know that studies are still ongoing in kids. We have to be knowledgeable about that and not just make the assumption that parents don’t want to vaccinate their kids for some crazy reason,” Benjamin says.

The complexities of the COVID-19 vaccine consent issue underscore the importance of a good patient/physician relationship. “At the end of the day, this is why it’s important to have every patient linked to a primary care practice. Trust doesn’t get built overnight, either with the patient or with their families,” Benjamin observes.

Providers should supply minors with age-appropriate information about the benefits and risks of vaccination and should rely on their state’s mature minor standard to determine competency.2 Some vaccine-hesitant parents perceive expanded autonomy to minors as a threat to their authority, acknowledges Larissa Morgan, JD, MBE. “But minors of vaccine-hesitant parents should not be placed at an increased risk of contracting COVID-19 based on their parents’ own uncertainty. Indeed, some minors might possess a greater understanding of the benefits of vaccination than their parents,” Morgan says.

Competency determinations must balance the interests of parents with the autonomy of minors. “The burden to vaccine-hesitant parents’ interests by allowing minors to consent independently does not outweigh the significant individual and public health benefits of increased vaccination rates,” Morgan says.

REFERENCES

  1. Truong D. Parents take aim at D.C. law that lets minors get vaccinated without permission. National Public Radio. July 19, 2021.
  2. Morgan L, Schwartz JL, Sisti DA. COVID-19 vaccination of minors without parental consent: Respecting emerging autonomy and advancing public health. JAMA Pediatr 2021; Jul 12. doi: 10.1001/jamapediatrics.2021.1855. [Online ahead of print].