1.5.2 Medical Decision-Making and Mature Minors
Michelle Jackman, MD, MSc, FRCPC; and, Andrew McRae MD, PhD, FRCPC
Updated December 1, 2013
- To understand the legal and ethical considerations in decision-making by minors.
- To learn how to determine whether a minor has capacity to make health care decisions.
Susan is a 14-year-old girl with ulcerative colitis. She has been receiving medical therapy since her diagnosis two years ago. She is admitted to the in-patient general pediatric ward for an exacerbation of her disease, requiring systemic steroids. On the fifth day of her admission, she develops acute abdominal pain, fever and hypotension. Her laboratory tests reveal leukocytosis and hypoalbuminemia. Computed tomography imaging shows evidence of toxic megacolon, which is an indication for urgent surgical intervention. The surgeon on call is consulted and explains to Susan and her parents the need for urgent laparotomy.
Susan refuses to undergo surgery, citing fears of scarring. The surgeon is concerned that she does not understand that declining surgery may lead to sepsis and death. The parents want her to proceed with the surgery. Susan tells her parents about her concerns about scarring and the importance of her body image to her overall well-being and confidence. She states that she would rather risk death than have a scar.
- Does Canadian law define an age of decision-making capacity?
- Are there any professional society guidelines on the issue of decision-making by minors?
- How does one determine the capacity for decision-making in adolescents? What are the similarities between adults and adolescents?
- Are there any differences in this capacity between adolescents and adults?
- How would you manage this case if the consensus was that Susan was incapable?
- How would you manage this case if Susan is determined to be capable?
- Gilmour JM. Children, adolescents, and health care. In: Downie J, Caulfield T, Flood C, editors. Canadian health law and policy. 2nd edition. Toronto: Butterworths; 2002. pp. 204–49.
- College of Physicians and Surgeons of Ontario. Consent to medical treatment, Policy #4-05 [reviewed and updated September 2005]. College of Physicians and Surgeons of Ontario; 2006. Available from: http://www.cpso.on.ca/Policies/consent.htm
- College of Physicians and Surgeons of Alberta. Consent for minor patients. College of Physicians and Surgeons of Alberta; 2006. Available from: http://www.cpsa.ab.ca/publicationsresources/attachments_other/Consent_for_Minor_Patients.pdf
- College of Physicians and Surgeons of British Columbia. Consent of “minors”: Infants Act. In: Physician resource manual. College of Physicians and Surgeons of British Columbia; n.d. Available from: https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/interantmedical
- College of Physicians and Surgeons of British Columbia. Care of the adolescent in hospital and in ambulatory care. In: Physician resource manual. College of Physicians and Surgeons of British Columbia; n.d. Available from: https://www.cpsbc.ca/cps/physician_resources/publications/resource_manual/careofadolescentathospital
- Manitoba Law Reform Commission. Consent to medical treatment. In: Substitute consent to health care. Report No. 110. Winnipeg: Office of the Queen’s Printer; 2004. pp. 5–9. Available from (on College of
Physicians and Surgeons of Manitoba website): http://www.manitobalawreform.ca/pubs/pdf/archives/110-full_report.pdf
- Salte B. Recent legislative change. College Newsletter [of the College of Physicians and Surgeons of Saskatchewan] 2002; 18(51): 7. Available from: http://www.quadrant.net/cpss/pdf/CPSS_December_Newsletter.pdf
- Government of Ontario. Health Care Consent Act, 1996 [last amendment 2007], c. 2. Available from: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm
- Bioethics Committee, Canadian Paediatric Society. Treatment decisions regarding infants, children and adolescents [Reference No. B04-01; reaffirmed February 2016]. Paediatrics & Child Health 2004; 9(2): 99–103. Available from: http://www.cps.ca/documents/position/treatment-decisions
- Committee on Pediatric Emergency Medicine. Consent for emergency medical services for children and adolescents. Pediatrics 2003; 111(3): 703–6.
- Sigman G, Silber TJ, English A, Epner JE. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. Journal of Adolescent Health 1997; 21: 408–15.
- Doig C, Burgess E. Withholding life-sustaining treatment: are adolescents competent to make these decisions? CMAJ: Canadian Medical Association Journal 2000; 162(11): 1585–8.
- Weithorn LA, Campbell SB. The competency of children and adolescents to make informed decisions. Child Development 1982; 53: 1589–98.
- Nwomeh BC, Waller AL, Caniano DA, Kelleher KJ. Informed consent for emergency surgery in infants and children. Journal of Pediatric Surgery 2005; 40(8): 1320–5.
- Pinnock R, Crosthwaite J. When parents refuse consent to treatment for children and young persons. Journal of Paediatrics and Child Health 2005; 41: 369–73.