Authors
Kelly A Olson, MD, MA
Amy B Middleman, MD, MPH, MS Ed
Section Editors
Abigail English, JD
Diane Blake, MD
Deputy Editor
Mary M Torchia, MD
Disclosures: Kelly A Olson, MD, MA Nothing to disclose. Amy B Middleman,
MD, MPH, MS Ed Grant/Research Support: Novartis [immunizations;
developing student curricula]; Merck [immunizations; public demonstration
project]. Abigail English, JD Nothing to disclose. Diane Blake, MD Nothing
to disclose. Mary M Torchia, MD Employee of UpToDate, Inc. Contributor
disclosures are reviewed for conflicts of interest by the editorial group.
When found, these are addressed by vetting through a multi-level review
process, and through requirements for references to be provided to
support the content. Appropriately referenced content is required of all
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All topics are updated as new evidence becomes available and our peer
review process is complete.
Literature review current through: Nov 2014. | This topic last updated: Oct
23, 2014.
INTRODUCTION The concepts of informed consent and confidentiality
are complex when the patient is an adolescent. This is particularly true
when the needs and wishes of the adolescent conflict with the opinions
and preferences of the parents [1].
Clinicians who treat adolescents must be aware of the federal and state
laws related to adolescent consent and confidentiality. The circumstances
in which adolescents may consent for their own care and in which
confidentiality is protected vary from state to state depending upon the
adolescent's status as a minor or adult, the service involved, and the
provider's level of concern regarding harm to the patient or others.
The basic laws governing consent for health care are state laws; clinicians
who treat adolescents need to be aware of the laws in their state.
Confidentiality provisions are found in both state and federal law.
Clinicians who treat adolescents also must be aware of the guidelines
governing federal and state funding sources for particular services,
particularly when funding source guidelines contain specific requirements
related to confidentiality. They should also be familiar with the consent
and confidentiality policies of the facility in which they practice, and they
must be aware of potential ways in which confidentiality can be
compromised (eg, record keeping, billing statements, insurance claims).
Mature minors
Mature minor "Mature minor" is a category of minor status that is
recognized in some states as an exception to the rules requiring parental
consent for medical care [8]. The mature minor doctrine, which was
originally created by courts and has been incorporated into statutes in a
few states, allows mature minors to consent to routine, nonemergent care,
especially when the risk of treatment is considered to be low [6,9].
Being at least 14 years old; by the age of 14, most adolescents have
cognitive skills and medical decision-making capacities similar to those of
adults [3,12]. Individual states may require a different minimal age for
mature minors in their statutes or court decisions.
Ability to understand risks and benefits of the proposed treatment
(based on the clinician's judgment).
Ability to provide the same level of informed consent as an adult (based
on the clinician's judgment) and actually giving consent.
Several factors must be considered when a clinician is assessing an
adolescent patient for maturity. These include chronologic age; the risk,
necessity, and benefit of the proposed treatment; and the adolescent's
emotional and cognitive capacity for understanding the treatment
information [13].
Although the following factors may not be legally required to conclude that
a minor is mature under the mature minor doctrine, when considering the
adolescent's emotional and cognitive capacity for understanding the
treatment information, it is important for the clinician to consider [14,15]:
CONSENT
Clinicians are often uncertain whether they can be held legally responsible
if they provide care based on the consent of a minor. If a minor is
authorized by law to provide consent, there is little likelihood that a
clinician would be held liable based on a failure to obtain parental consent.
Mature minors In the states that permit mature minors to consent for
medical care, several criteria should be met before treatment [7,23]:
In acute cases of rape, incest, and sexual abuse, the laws governing
emergency care apply [6,26,27]. Clinicians may be required to notify
parents or guardians except when there is suspicion that they may be one
of the perpetrators [6].
Federal statutes and regulations for the Title X Family Planning Program
and the Medicaid program require that confidential family planning
services be available to adolescents as well as adults. This effectively
precludes requiring parental consent for these services, as they would no
longer be confidential. Two states (Texas and Utah) specifically prohibit the
use of state funds for contraception without parental notification; a small
number of other states allow for, but do not require, notification by the
provider under certain circumstances (eg, if it is necessary to protect the
health of the minor) [3,28].
doctrine unless she is unable to give informed consent. Among the states
that explicitly permit minors to consent, approximately one-third permit a
clinician to inform the minor's parents under certain circumstances (eg, if
it is necessary in order to protect the health of the minor) [31]. For
updated information, please see the Guttmacher Institute Website.
Drug or alcohol care Nearly all states allow minors to consent for
services related to counseling or treatment for substance abuse, and
many of these permit, but do not require, parental notification [14,34].
When minors and parents disagree about treatment for substance abuse,
some states defer to the minor and some to the parent, but the majority
do not specify whether the minor's or the parent's decision is controlling
[34].
Parents may not be aware that adolescents can provide consent for the
treatment of drug or alcohol dependency [14]. In a survey of the parents
of adolescents from one Midwestern state, only 13 percent of parents
knew their state law permitted adolescents to consent for treatment of
drug or alcohol dependency; 23 percent thought such a law was bad, 52
percent thought it was good, and 24 percent thought it was neither [1].
Most states allow parents to admit their minor child to an inpatient facility
without the minor's consent [3,23].
parents are usually not FINANCIALLY liable unless they have agreed to pay
for treatment, are involved in the treatment decision, or the minor lives at
home and the treatment is considered necessary [3,7,23].
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