Mature minor doctrine
Encyclopedia
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. 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.
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, 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.
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.
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. The decades of accumulated evidence tended to demonstrate that children are capable of participating in medical decisionmaking in a meaningful way; and legal and medical communities have demonstrated an increasing willingness to formally affirm decisions made by young people even regarding life and death.
In 1990, the United States Congress
passed the Patient Self-Determination Act
; even though key provisions apply only to patients over age 18, 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.
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.
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,
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:
A "dissenting" opinion by Justice Ian Binnie
went even further:
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".
Common law
Common law is law developed by judges through decisions of courts and similar tribunals rather than through legislative statutes or executive branch action...
policy accepting that an unemancipated minor patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
may possess the maturity
Maturity (psychological)
Maturity is a psychological term used to indicate how a person responds to the circumstances or environment in an appropriate manner. This response is generally learned rather than instinctive, and is not determined by one's age...
to choose or reject a particular health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
, sometimes without the knowledge or agreement of parents, and should be permitted to do so. It is now generally considered a form of patients rights
Rights
Rights are legal, social, or ethical principles of freedom or entitlement; that is, rights are the fundamental normative rules about what is allowed of people or owed to people, according to some legal system, social convention, or ethical theory...
; formerly, the Mature Minor Rule was largely seen as protecting health care providers from criminal and civil claims
Cause of action
In the law, a cause of action is a set of facts sufficient to justify a right to sue to obtain money, property, or the enforcement of a right against another party. The term also refers to the legal theory upon which a plaintiff brings suit...
by parents of minors at least 15 years of age.
Jurisdictions may codify an 'age of medical consent', may accept the judgment of licensed
Licensure
Licensure refers to the granting of a license, which gives a "permission to practice." Such licenses are usually issued in order to regulate some activity that is deemed to be dangerous or a threat to the person or the public or which involves a high level of specialized skill...
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, 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
Government agency
A government or state agency is a permanent or semi-permanent organization in the machinery of government that is responsible for the oversight and administration of specific functions, such as an intelligence agency. There is a notable variety of agency types...
or court
Court
A court is a form of tribunal, often a governmental institution, with the authority to adjudicate legal disputes between parties and carry out the administration of justice in civil, criminal, and administrative matters in accordance with the rule of law...
. The mature minor doctrine is sometimes, but not always, connected with enforcing confidentiality of minor patients from their parents.
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."
Medical emancipation
By definition, a "mature minor" has been found to have the capacityCapacity (law)
The capacity of both natural and legal persons determines whether they may make binding amendments to their rights, duties and obligations, such as getting married or merging, entering into contracts, making gifts, or writing a valid will...
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
Reproductive health
Within the framework of the World Health Organization's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system...
services, thereby permitting medical treatment without parental consent and, often, confidentiality from parents. A limited guardianship
Legal guardian
A legal guardian is a person who has the legal authority to care for the personal and property interests of another person, called a ward. Usually, a person has the status of guardian because the ward is incapable of caring for his or her own interests due to infancy, incapacity, or disability...
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.
History
One early U.S. case of significance, Smith v. Seibly, 72 Wn.2d 16, 431 P.2dPacific Reporter
The Pacific Reporter, Pacific Reporter Second and Pacific Reporter Third are United States regional case law reporters. It is part of the National Reporter System created by John B...
719 (1967), before the Washington Supreme Court
Washington Supreme Court
The Washington Supreme Court is the highest court in the judiciary of the U.S. state of Washington. The Court is composed of a Chief Justice and eight Justices. of the Court are elected to six-year terms...
, establishes precedent on the mature minor doctrine. The plaintiff, Albert G. Smith, an 18-year-old married father, was suffering from myasthenia gravis
Myasthenia gravis
Myasthenia gravis is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability...
, 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
Vasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...
. His doctor required written consent
Informed consent
Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...
, which Smith provided, and the surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
was performed. Later, after reaching Washington's statutory age of majority
Age of majority
The age of majority is the threshold of adulthood as it is conceptualized in law. It is the chronological moment when minors cease to legally be considered children and assume control over their persons, actions, and decisions, thereby terminating the legal control and legal responsibilities of...
, 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
Pacific Reporter
The Pacific Reporter, Pacific Reporter Second and Pacific Reporter Third are United States regional case law reporters. It is part of the National Reporter System created by John B...
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. The decades of accumulated evidence tended to demonstrate that children are capable of participating in medical decisionmaking in a meaningful way; and legal and medical communities have demonstrated an increasing willingness to formally affirm decisions made by young people even regarding life and death.
In 1990, the United States Congress
United States Congress
The United States Congress is the bicameral legislature of the federal government of the United States, consisting of the Senate and the House of Representatives. The Congress meets in the United States Capitol in Washington, D.C....
passed the Patient Self-Determination Act
Patient Self-Determination Act
The Patient Self-Determination Act was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990...
; even though key provisions apply only to patients over age 18, the legislation advanced patient involvement in decisionmaking. The West Virginia Supreme Court, in Belcher v. Charleston Area Medical Center, 422 S.E.2d
South Eastern Reporter
The South Eastern Reporter and South Eastern Reporter Second are United States regional case law reporters. It is part of the National Reporter System created by John B...
827, 188 W.Va. 105 (1992), defined a "mature minor" exception to parental consent
Parental consent
Parental consent laws in some countries require that one or more parents consent to or be notified before their minor child can legally engage in certain activities....
, 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.
United States
In the United States, bodily integrityBodily integrity
Bodily integrity, otherwise known as physical or corporal integrity, is a concept that refers to the inviolability of the physical body. It is one of Martha Nussbaum’s ten principle capabilities . She defines bodily integrity as: “Being able to move freely from place to place; being able to be...
has long been considered a common law right; the United States Supreme Court, in 1891's Union Pacific Railway Company v. Botsford
Union Pacific Railway Company v. Botsford
Union Pacific Railway Company v. Botsford, was a case before the United States Supreme Court.A railroad passenger sustained permanent injuries to her brain and spinal cord. She sued the railroad for negligence in the construction of the railroad car which allegedly caused her injuries...
, 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
Rational-legal authority
Rational-legal authority is a form of leadership in which the authority of an organization or a ruling regime is largely tied to legal rationality, legal legitimacy and bureaucracy...
." The Supreme Court in 1990 (Cruzan v. Director, Missouri Department of Health
Cruzan v. Director, Missouri Department of Health
Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 , was a United States Supreme Court case argued on December 6, 1989 and decided on June 25, 1990...
) allowed that "constitutionally protected liberty interest
Claim rights and liberty rights
Some philosophers and political scientists make a distinction between claim rights and liberty rights. A claim right is a right which entails responsibilities, duties, or obligations on other parties regarding the right-holder...
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.
In 1989, the Supreme Court of Illinois
Supreme Court of Illinois
The Supreme Court of Illinois is the state supreme court of Illinois. The court's authority is granted in Article VI of the current Illinois Constitution, which provides for seven justices elected from the five appellate judicial districts of the state: Three justices from the First District and...
interpreted the Supreme Court of the United States
Supreme Court of the United States
The Supreme Court of the United States is the highest court in the United States. It has ultimate appellate jurisdiction over all state and federal courts, and original jurisdiction over a small range of cases...
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 casesAbortion in the United StatesAbortion in the United States has been legal in every state since the United States Supreme Court decision in Roe v. Wade, on January 22, 1973...
, the [Illinois] appellate courtAppellate courtAn appellate court, commonly called an appeals court or court of appeals or appeal court , is any court of law that is empowered to hear an appeal of a trial court or other lower tribunal...
found such an extension "inevitable." ...Nevertheless, the Supreme Court has not held that a constitutionally based rightConstitutional rightAn inalienable right is a freedom granted by a Nature or the Creator's endowment by birth , and may not be legally denied by that government.-United States:...
to refuse medical treatmentInformed refusalInformed refusal is a medico-legal concept whereby a person can be said to have given refusal to an intervention based upon an understanding of the facts and of the implications of not following a recommended diagnostic or therapeutic action...
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].
Canada
In 2009, the Supreme Court of CanadaSupreme Court of Canada
The Supreme Court of Canada is the highest court of Canada and is the final court of appeals in the Canadian justice system. The court grants permission to between 40 and 75 litigants each year to appeal decisions rendered by provincial, territorial and federal appellate courts, and its decisions...
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
Puisne Justice
A Puisne Justice or Puisne Judge is the title for a regular member of a Court. This is distinguished from the head of the Court who is known as the Chief Justice or Chief Judge. The term is used almost exclusively in common law jurisdictions such as England, Australia, Kenya, Canada, Sri Lanka,...
Rosalie Abella
Rosalie Abella
Rosalie Silberman Abella, is a Canadian jurist. She was appointed in 2004 to the Supreme Court of Canada, becoming the first Jewish woman to sit on the Canadian Supreme Court bench.- Early life :...
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" opinion by Justice Ian Binnie
Ian Binnie
William Ian Corneil Binnie was a puisne justice of the Supreme Court of Canada, serving from 1998 to 2011. Of the justices appointed to the Supreme Court in recent years, he is one of the few to have never sat as a judge prior to his appointment.- Personal life and career as lawyer :Binnie was...
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 judgeJudgeA judge is a person who presides over court proceedings, either alone or as part of a panel of judges. The powers, functions, method of appointment, discipline, and training of judges vary widely across different jurisdictions. The judge is supposed to conduct the trial impartially and in an open...
’s consideration of what the judge believes to be the young person’s best interests."
Analysts note that the Canadian decision merely requires that younger patients be permitted a hearing
Hearing (law)
In law, a hearing is a proceeding before a court or other decision-making body or officer, such as a government agency.A hearing is generally distinguished from a trial in that it is usually shorter and often less formal...
, and still allows a judge to "decide whether or not to order a medical procedure on an unwilling minor".