The dispute over COVID-19 vaccines isn’t just playing out on political, racial and socioeconomic lines. It’s also creating disagreements between parents and their kids.
When adolescents and their parents disagree on whether to get COVID-19 vaccinations, it introduces fundamental legal and ethical issues for physicians, including around autonomy, capacity and informed consent.
During a recent “Ethics Talk” videocast from the AMA Journal of Ethics® (@JournalofEthics), Abigail English, a lawyer who directs the Center for Adolescent Health & the Law, in Chapel Hill, North Carolina, outlined how to approach the challenges that arise when adolescent patients seeking the COVID-19 vaccine are not supported by their parents.
Parental support is important in a child’s health care, so when a person under the legal age of adulthood—which is 18 in most states—and a parent disagree about a health care decision, it's important to explore the cause of the disagreement and whether there are ways to close the gap.
“Sometimes disagreement is based on a different understanding of the facts and the evidence,” English said. “In these situations, it may be possible to promote agreement by [pointing to] the evidence and providing a fuller interpretation of the facts.”
That may include going over what COVID-19 vaccines do and how they work, as well as the risks of receiving the vaccine compared with the risk of coronavirus infection.
"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,” English said. “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.”
Other times, however, disagreement is based on differing values, which can be much more difficult to 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,” English said. “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.”
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When agreement is not possible, or when a parent or guardian is simply unavailable, and an adolescent wants to be vaccinated, the physician should first determine whether state law allows the adolescent to consent.
“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,” English said.
Criteria could include whether a youth is homeless or over a specific age, or if local law supports consent for prevention of communicable disease.
And then there’s the issue of capacity.
“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,” she added, noting that this requires adolescents to understand the risks and benefits of the procedure or treatment.
“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,” English said.
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