Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the journal's editor in chief, Dr Audiey Kao, with Abigail English, Director of the Center for Adolescent Health and Law in Chapel Hill, North Carolina, about the ethical and legal implications of adolescents consenting for COVID-19 vaccination. To watch the full video interview, head to our site, JournalOfEthics.org, or check out our YouTube channel.
Dr Audiey Kao: Ms English, thank you for being a guest on Ethics Talk. [music fades out]
Abigail English: Thank you, Audiey. It's my pleasure to be here.
Kao: So, what do you see as the most compelling ethical and legal complexities in cases in which an adolescent and their parent or guardian disagree about a specific health care decision?
English: Thanks for that question, Audiey. It's a really important one that requires consideration of a wide range of ethical and legal issues: issues of autonomy, capacity, and informed consent as well as justice. A basic legal principle is that parent consent is required for minor children to receive health care. That generally includes adolescents who are under the age of 18; however, parents and children, as you pointed out, do not always agree about health care decisions, especially when the child reaches adolescence. When an adolescent turns 18, they are legally an adult and able to consent for their own health care, but disagreements with parents may still occur.
Under state laws, numerous exceptions to the rule requiring parental consent have been created that allow adolescents who are legally minors to consent to their own care, either because they have a certain status or because they are seeking a particular service. These laws serve both a public health purpose, such as by enabling adolescents to receive care for prevention, screening, diagnosis, and treatment for sexually transmitted infections, and the individual interests of adolescents themselves by expanding their access to health care and helping them protect themselves from harm. From a legal perspective, when an adolescent minor and their parent disagree about a health care decision, the adolescent may be allowed to consent for themselves, depending on the state law where they live. From both a legal and an ethical perspective, for an adolescent to be allowed to consent to their own care, the adolescent must have the capacity to give an informed consent. This requires that they understand the risks and benefits of the procedure or treatment and voluntarily agree to it.
Parental involvement in their children's health care, including care for their adolescent children, is an important source of support. A majority of adolescents voluntarily involve their parents in their health care decisions, even when they might have the legal right to consent for themselves. Unfortunately, though, some adolescents lack supportive parents or are separated entirely from their families. In these circumstances, or when an adolescent with the capacity to give an informed consent wants health care but the parent disagrees, it is important to look at whether the law allows the adolescent to consent for the care themselves, to carefully assess whether the adolescent has the capacity to give an informed consent, and to explore whether other trusted adults are available to support the adolescent.
Kao: Given what you just said, in May 2021, the Pfizer-BioNTech COVID-19 vaccine received Emergency Use Authorization from the US Food and Drug Administration in children age 12 to 15 years. Most state laws, however, do not authorize vaccination without parental consent. So, when young patients whose parents won't consent want to receive a COVID-19 vaccine, how should pediatricians and other health care professionals respond?
English: I think, Audiey, that whenever there is disagreement between an adolescent and a parent about a health care decision, it's important to carefully consider the reasons for the disagreement and to explore whether there's a basis for helping them reach agreement. In most situations, everyone involved—the adolescent, the parent, and the health care provider—want the best for the adolescent and want to protect their health. Sometimes disagreement is based on a different understanding of the facts and the evidence. In these situations that may be possible to promote agreement by explaining the evidence and providing a fuller interpretation of the facts.
In some situations, adolescents who want the COVID vaccine may be better informed than their parents about the underlying evidence. So, health care professionals might try to help both parent and adolescent reach a common understanding about what COVID-19 vaccines do, how they work, what the risks and benefits are of receiving the vaccine compared to the risks of coronavirus infection, and why it is important for adolescents to receive the vaccine. For example, many people believe that young people are not at great risk of being infected and that they don't get very sick if they are infected. Unfortunately, however, recent data are showing an increase in hospitalizations of adolescents and also that some children and adolescents are suffering from protracted symptoms, long COVID, or even organ damage.
Sometimes disagreement is based on different values, which can be more challenging to address and resolve. This may be especially likely with the COVID vaccine because of the widespread proliferation of misinformation and disinformation about the virus and the vaccine. From an ethical perspective, withholding a lifesaving vaccine from an adolescent based on misinformation would seem to violate the principle of justice. Even so, and even when parents want the best for their adolescent children, sometimes it will not be possible to reach agreement. When agreement is not possible or when parents are simply absent or entirely unavailable and the adolescent wants to be vaccinated, the health care professionals should determine first whether state law would allow the adolescent to consent, such as if the youth is homeless or over a specific age, or if the law supports consent for prevention of communicable disease, and next, whether the adolescent is capable of informed consent.
Kao: So, in light of that, the Tennessee Department of Health recently fired its Medical Director for Vaccine-Preventable Diseases and Immunization Programs after she circulated a memo explaining that state law in Tennessee allows clinicians to provide treatment without parental consent to older adolescents who have capacity to make medical decisions under the so-called mature minor doctrine. Given the politicization of this pandemic, how should public health officials be responding to meet CDC's recommendations that minors get vaccinated against COVID-19?
English: That's a really challenging question, Audiey. I would say that, first and foremost, public health officials should be doing everything they can to overcome vaccine hesitancy in its many dimensions and do that in a collaborative versus an adversarial way. This is a difficult challenge given the myriad reasons why different populations and different individuals are hesitant to accept the vaccine or reject it outright. Enlisting the support of all sectors in the community is essential in developing both approaches that will reach individuals and a collaborative strategy to reach the public at large. Primary care physicians and health care providers, religious leaders, political leaders, celebrities, members of the general public, parents, and adolescents themselves all have a role to play in dispelling myths, overcoming disinformation, and promoting evidence-based understanding about the vaccine and inspiring confidence in its safety and effectiveness. In a politicized environment, it is not easy to do this, but it is even more important to do so.
Because so much information and misinformation is spread via social media, and because youth are so comfortable with these forms of communication, it would be useful for public health officials to enlist youth themselves in outreach efforts to increase uptake of the vaccine among adolescents. This must be done with sensitivity to avoid excluding parents, but also taking advantage of the expertise adolescents can offer in helping to meet an important goal that will promote both their health and the public health.
Kao: So, as we near the end of our conversation, how do you think public policy responses to this pandemic would be different if more children were getting sick and dying?
English: I do think there's a perception that coronavirus does not pose a big risk for children and adolescents. Although the numbers are certainly smaller in this age group than among older adults and the elderly, the perception is not entirely accurate. Children and adolescents do get infected, and some get very sick indeed with COVID-19. If the numbers were much greater, the difference in scale might prompt some shifts in public policy. There are so many areas of public policy that are of critical importance for the health, safety, and well-being of children and adolescents in the context of the pandemic.
One area has to do with decisions about school closing and reopening, including physical safety issues such as improved ventilation, behavioral issues such as social distancing, and regulatory issues such as mask requirements or vaccine mandates. However, because public policy related to the pandemic often seems to be driven by political considerations as much as by public health evidence, it is difficult to predict exactly what the effects would be of a larger number of infections and deaths among children and adolescents.
At the same time, whether the number of infections and deaths in children and adolescents is small or large, any preventable deaths should be avoided, and public policy should be designed to reach that goal. From an ethical perspective, withholding a lifesaving vaccine from an adolescent who wants it and has the capacity to give an informed consent seems both unjust and a violation of the ethical principle of autonomy. An important societal goal is to find ways to overcome vaccine hesitancy so that disagreements between adolescents and their parents will not occur, or only very rarely. Short of that, allowing well informed and capable adolescents to consent for themselves would be a just outcome.
Kao: On that note, I want to thank Abigail English for sharing her expertise and insights with our audience today. Abigail, thanks again for being a guest on Ethics Talk today.
English: It was my pleasure. I really enjoyed the conversation with you today, Audiey.
Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. Thank you for being with us today. We'll see you next time on Ethics Talk. [bright theme music plays]
Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.