Mature minor doctrine

The mature minor doctrine is a rule of law found in the United States and Canada 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.
Jurisdictions may codify an age of medical consent, accept the judgment of licensed providers regarding an individual minor, or 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 at least 16 may be assumed to be mature minors for this purpose, patients aged 13 to 15 may be designated so by licensed providers, and pre-teen patients may be so-designated after evaluation by an agency or court. The mature minor doctrine is sometimes 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."
Medical emancipation.
By definition, a "mature minor" has been found to have the capacity to make serious medical decisions alone. By contrast, "medical emancipation" formally releases children from some parental involvement requirements but does not necessarily grant that decision making to children themselves. 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.
History.
One significant early U.S. case, "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 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: "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 decision-making 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.
Religious beliefs have repeatedly influenced a patient's decision to choose treatment or not. In a case in 1989 in Illinois, a 17 year old female Jehovah's Witness was permitted to refuse necessary life saving treatments.
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 decision-making. 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.
Laws by jurisdiction.
Canada.
The Supreme Court of Canada recognized mature minor doctrine in 2009; in provinces and territories lacking relevant statutes, common law is presumed to be applied.
United States.
Several states permit minors to legally consent to medical treatment without parental consent or over parental objections. In addition, many other states allow minors to consent to medical procedures under a more limited set of circumstances. These include providing limited minor autonomy only in enumerated cases, such as blood donation, substance abuse, sexual and reproductive health (including abortion and sexually transmitted infections), or for emergency medical services. Many states also exempt specific groups of minors from parental consent, such as homeless youth, emancipated minors, minor parents, or married minors. Further complicating matters is the interaction between state tort law, state contract law, and federal law, depending on if the clinic accepts federal funding under Title X or Medicaid.
Withholding of consent.
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, "No 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 right. Nevertheless, lower courts have increasingly held that competent patients have the right to refuse any treatment for themselves.
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,
An ongoing case of Z.M is being heard in Maryland regarding the minor's right to refuse chemotherapy.
In Connecticut, Cassandra C. a seventeen year old was ordered by the Connecticut Supreme Court to receive treatment. The court decided that Cassandra was not mature enough to make medical decisions.
Canada.
In 2009, the Supreme Court of Canada ruling in "A.C. v. Manitoba" [2009] SCC 30 (CanLII) found that children "may" make life and death decisions about their medical treatment. In the majority opinion, Justice Rosalie Abella wrote:
A "dissenting" opinion by Justice Ian Binnie would have gone 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".