In a recent issue of The Journal of Medicine and Philosophy, Brian Partridge provides a thoughtful review of the scope, history, psychologic and neurophysiologic aspects of the concept of the mature minor as it relates to medical care.1 As a general rule, persons under the age of legal majority are considered incapable of providing legal consent for medical care. The consent of a parent or guardian is required for medical intervention except when a parent or guardian is not available to provide consent and the child would likely suffer harm if medical intervention is not provided emergently. Over the past 50 years, however, the circumstances under which minors are allowed to provide legal consent on their own behalf have expanded to include a number of nonemergent situations, including the provision of birth control and pregnancy-related care, the diagnosis and treatment of sexually transmitted diseases, and the treatment of psychiatric conditions and drug and alcohol addiction. States also allow emancipated minors to consent to or decline medical treatment more generally. In most states, emancipated status requires that the minor be legally married, an active duty member of the armed forces, living independently from parents and managing his or her own resources, and/or have a declaration of emancipation by the court. Finally, most states have also adopted mature minor statutes that allow older adolescents (usually above the age of 14) to consent to medical care if they can demonstrate that they are intellectually capable of making a reasonable medical decision.
There is growing empirical evidence that the adolescent brain is a work in progress. The prefrontal cortex, which is responsible for cognition, impulse control, and most executive functions, is not fully developed until the early to mid-20s. The limbic subcortical/dopamine system, the part of the brain responsible for behaviors motivated by emotion, immediate sensation, and reward-seeking, appears to be fully developed by age 14 to 15 years. The still-developing prefrontal cortex is less capable of restraining intense emotions or providing a serious cost/benefit analysis in situations where an immediate reward presents itself. The mature adolescent may have the intellectual capacity to recognize a risky choice and even argue against it, but in an emotionally charged situation the same adolescent may be unable to refrain from engaging in the risky behavior. In addition, peer pressure exerts considerable influence on the decision-making of the adolescent.
In recent years, some courts have begun to recognize the implications of ongoing brain development in adolescents, in particular the underdeveloped sense of responsibility and the tendency to make impulsive and poorly considered decisions. As a result, some courts do not apply the same penalty to a crime committed by an adolescent that would be applied if the same crime were committed by an adult. The US Supreme Court abolished adolescent capital punishment in 2005 for similar reasons.
Developing autonomy and independence is an important goal as children move through adolescence toward adulthood. Self-determination depends on a set of cognitive, psychological, and social skills that develop gradually. The...