What is the Mature Minor Doctrine?

Introduction

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.

Refer to Gillick Competence, Marion’s Case, Informed Consent, and Informed Refusal.

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 capacity for decisional autonomy, or the right to make decisions including whether to undergo risky medical but potentially life-saving medical decisions alone, without parental approval. 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.

Brief History

One significant early US 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 09 March 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 paediatric 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 Centre (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.

The 2000s and 2010s experienced a number of outbreaks of vaccine-preventable diseases, such as the 2019-2020 measles outbreaks, which were fuelled in part by vaccine hesitancy. This prompted minors to seek vaccinations over objections from their parents. Beginning in the 2020s during the COVID-19 pandemic, minors also began seeking out the COVID-19 vaccine over the objections of their vaccine-hesitant parents.

Laws by Jurisdiction

Canada

The Supreme Court of Canada recognised mature minor doctrine in 2009; in provinces and territories lacking relevant statutes, common law is presumed to be applied.

Province/TerritoryMinimum AgeOutline
AlbertaNoneThe Child, Youth and Family Enhancement Act does not establish a minimum age. In practice, children at 16 are generally considered capable of consent to medical procedures; in some cases, the doctrine has been applied to children as young as 14.
British ColumbiaNoneThe Infants Act does not set an age at which a child becomes capable of consent to medical procedures, but the child must be capable of understanding the procedure and its risks in order to consent.
ManitobaNoneIt is presumed minors 16 and older can provide consent; minors 15 and younger and presumed to be incapable of consent but this can be rebutted.
New BrunswickNoneUnder the Medical Consent of Minors Act, minors 16 and older can consent to medical procedures. Minors under 16 can consent to treatment if they can demonstrate an understanding of the procedure and its consequences.
Newfoundland and LabradorNoneThe Advanced Health Care Directives Act presumes minors 16 and older are capable of consent to treatment.
Northwest TerritoriesNoneNo statute exists in Northwest Territories dictating an age of consent; absent a statute, common law applies.
Nova ScotiaNoneMedical procedures can be performed on any person capable of providing informed consent.
NunavetNoneNo statute exists in Nunavut dictating an age of consent.
OntarioNoneThe Health Care Consent Act allows all persons capable of informed consent to agree to treatment. The Substitute Decisions Act presumes all persons 16 or older can give or withhold consent to care.
Prince Edward IslandNoneMedical procedures can be performed on any person capable of providing informed consent.
Quebec14Minors 14 and older may consent to medical care but still require parental consent for optional procedures that involve significant risks, e.g. cosmetic surgery.
SaskatchewanNoneMedical procedures can be performed on any person capable of providing informed consent.
YukonNoneMedical procedures can be performed on any person capable of providing informed consent.

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.

StateMinimum AgeOutline
Alabama14Minors 14 years or older or who have graduated high school can consent to medical procedures. No evaluation of maturity required. Parental consent is required for abortion but can be bypassed.
AlaskaNoneNo evaluation of maturity required. Parental consent is not required for abortion, as this violates the Constitution of Alaska’s clause protecting privacy.
ArkansasNoneAny minors capable of informed consent.
California12CA Family Code 6926 permits minors to consent to immunization against sexually transmitted infections.
DelawareNone“Reasonable efforts” must have first been made to secure parental consent. Minors can consent to vaccinations for sexually transmitted infections.
IdahoNoneAny minors capable of informed consent.
IllinoisNoneAny minors capable of informed consent, but informed refusal of medical treatment can be overruled.
Kansas16Minors aged 16 are permitted de jure to consent to medical treatment when no parent is available. Mature minors are permitted to consent to medical treatment, but maturity must be assessed on a case-by-case basis.
LouisianaNoneMinors are allowed to consent to any medical procedure they deem necessary.
MaineNoneA mature minor’s wishes expressed in a living will must be considered.
MassachusettsNoneMature minors meeting are permitted to consent to medical treatment, but only if their “best interests … will be served by not notifying his or her parents of intended medical treatment.”
MinnesotaNoneMinnesota Statutes §144.3441 permits minors to consent to immunisation against Hepatitis B.
MontanaNoneAny minors who have completed high school are able to consent to medical treatment.
NevadaNoneMature minors meeting are permitted to consent to medical treatment, but only if the healthcare worker believes the minor would risk a “serious health hazard” absent treatment.
New YorkNoneNY Public Health Law §2305 permits minors to consent to treatment for and immunization against sexually transmitted infections.
Oregan15Minors aged 15 and up have the authority to consent to (but not necessarily refuse) medical treatment.
Pennsylvania18Minors aged 18 or who have completed high school can consent to medical treatment.
South Carolina16Minors aged 16 and up can consent to any medical treatment other than “operations”.
Tennessee7Any mature minors capable of informed consent can consent to medical procedures. The courts make the rebuttable presumption that minors aged 7 to 13 are not mature, while minors 14 and up are.
WashingtonNoneMature minors may consent to medical procedures, including immunisations.
Washington D.C.12Minors 12 and older may consent to immunisation with CDC-approved vaccines, even over parental objections. The law compels healthcare providers to seek payment directly from insurance companies without notifying parents.
West VirginiaNoneAny minors capable of informed consent can consent to medical procedures.

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:

Although the United States Supreme Court has not broadened this constitutional right of minors beyond abortion cases, the [Illinois] appellate court found such an extension “inevitable.” …Nevertheless, the Supreme Court has not held that a constitutionally based right to refuse medical treatment 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].

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:

“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 would have gone 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 judge’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, and still allows a judge to “decide whether or not to order a medical procedure on an unwilling minor”.

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