State Versus Adolescent Override for Parental Refusals to Vaccinate Against COVID-19

Traditionally in the United States, parental permission is required for pediatric health care, including vaccination. The rationale is that minors are presumed to lack the decision-making capacity for health care and their parents are their presumed surrogate decision makers. Four common justifications for parental decision-making authority are (1) parents usually care deeply about their child’s welfare, know them and their needs best, and are best positioned to make decisions that serve their child’s welfare, (2) parents bear the consequences of their choices, (3) respect for parental freedom, within limits, to raise their children according to their own values and to seek to transmit these values to their children, and (4) respect for the family as a valuable institution requires some degree of freedom and privacy in decision making about the welfare of its child members.^6,7 

To increase the uptake of adolescent vaccinations, states can adopt any of 3 different strategies. The first holds that adolescents have decisional capacity similar to adults and should be empowered to make their own health care decisions (autonomy). The second is to justify exemptions that sidestep parental permission on the grounds that requiring parental involvement in some sensitive situations could lead to delays that seriously threaten the minor’s wellbeing (best interest). The third is to support state-sanctioned school mandates on public health grounds. Let us consider each strategy and its moral underpinnings.

First, the justification to empower adolescents to make health care decisions begins with the assumption that adolescents have decisional capacity comparable to adults. One highly cited study asked subjects at 4 different ages (9, 14, 18, and 21) about 4 hypothetical medical dilemmas and found that “the performance of the fourteen-year-olds was generally equivalent to that of the adults.”⁸  Their performance was “generally equivalent” unless the life-saving medication had a negative impact on body image (eg, hirsutism from antiseizure medication), suggesting some degree of poor judgment. More problematic is that hypothetical studies may not accurately capture the difference between adolescents and young adults because they better capture cognitive development and not necessarily one’s social and emotional maturity to make an informed decision in a clinical setting under conditions of stress and uncertainty.^5,9  To be fair, “research on decision making under conditions of uncertainty indicates that neither adolescents nor adults perform at an optimal level under many circumstances involving complex decisions.”⁵  However, there are data to reveal that adolescents do make worse decisions than adults under stress.^5,9 

The argument to permit adolescents to consent alone for health care also hinges on the argument that if adolescents generally can make decisions that are as good as adults, then they should have the authority to do so. Although decisional capacity is necessary for health care decision-making authority, it is not necessarily sufficient.⁷  First, parents are responsible for the child’s wellbeing and this empowers them to make decisions not just in health care but in many spheres of life. Depending on the state in which the child lives and the child’s age, the child cannot play in a sports league, apply for a driver’s permit, or work without parental permission. Second, although parents are supposed to make decisions that are in their child’s best interest, parents are given some degree of discretion to raise their child according to their own values. Parents may be wrong about what is best for their child, the child may not want to share in his or her parents’ lifestyle, but the parents are the guardians and have the right to try to inculcate their values.^6,7  This is not to say that parents should ignore their adolescents’ preferences, only that the state should not intervene unless the parents’ decision reaches a level of abuse or neglect.^6,7 

Second, one can argue that, even if minors do not have a capacity equivalent to adults, there are some sensitive situations (eg, mental health and contraceptive care) in which requiring parental involvement could lead to a harmful delay in diagnosis and treatment. Specialized consent statutes permit minors to consent for themselves for such services. Although adolescents may want to be vaccinated against COVID-19 to protect themselves, their family, and their friends, the exemptions have traditionally focused on sensitive health issues like mental health and reproductive care about which adolescents may have a hard time talking to parents. Respiratory infections are not generally considered a sensitive topic. Now, to the extent that COVID-19 vaccination has become politicized, it may be hard for some adolescents to talk to their parents and they may want to consent to vaccination without parental involvement to avoid negative repercussions that may occur were their parents to learn of their being vaccinated, ranging from tension in the parent–child relationship, punitive measures taken by parents to prevent the minor from getting vaccinated, or, in extreme cases, abuse directed at the minor.⁵ 

The specialized consent statutes are designed to increase the uptake of necessary care. However, it is unknown whether a strategy that authorizes adolescents to consent for immunizations will increase vaccine uptake and promote their wellbeing. One study found a 7% increase in HPV vaccination in states in which adolescents or parents can consent for the HPV vaccine (although who actually consented is unknown) versus states in which parental consent was needed.¹⁰  One explanation for the small impact is that minors typically internalize their parents’ values. This suggests that most adolescents who live with adults unvaccinated against COVID-19 will not independently seek vaccination. Even if adolescents would prefer to be vaccinated, strong disagreement strains family relationships, particularly if parents have a history of conscientious objection to vaccines.⁹  Importantly, we do not know whether the number of adolescents willing to independently seek out vaccination will be greater or less than the number of parents who avoid getting their children vaccinated because of parental distrust of a health care system that allows their child to get vaccinated surreptitiously. The reverberations also may not be limited to COVID-19 vaccination; one possible implication of overriding parental vaccination authority is decreased parental trust manifested by parental avoidance of other preventive health care for their children. Thus, whether empowering adolescents would increase vaccine uptake is unknown, but a small increase may not outweigh the potential risk of harm and disruption that distrust can seed within the doctor–parent–adolescent relationship.

If we create a specialized consent statute-like exemption that allows adolescents to consent for COVID-19 vaccination, what happens if a teenager does not want to be vaccinated, but their parents authorize it? It is problematic to say that adolescents have the right to consent for themselves if they do not have the right to refuse vaccination. Weithorn and Reiss concede, “Our proposal is, to some extent, asymmetrical. It authorizes minors to consent to vaccines independent of their parents but does not authorize minors to refuse vaccines where their parents provide consent.”⁵  Authorizing adolescents to say “yes,” but not to say “no” is not about respect for their capacity or autonomy, but about the state imposing its value on what is best (vaccination). It sets a bad precedent for addressing whose permission is needed for beneficial medical care.

Third, states can mandate COVID-19 vaccinations. The state’s power to mandate vaccines for children is based on (1) its parens patriae interest to protect children who are vulnerable to promote their best interest and (2) its police power, which authorizes it to protect and promote public health.^3,5,9  Although the state can mandate adult vaccination, parens patriae and police power interests are more compelling for children.⁵  Statewide student vaccine mandates can be justified if (1) the problem is serious and (2) the intervention is safe and effective, as is the case for the severe acute respiratory syndrome coronavirus 2 and COVID-19 vaccines, respectively.

Parents are the presumptive surrogate decision makers for their children and this responsibility extends to most health care. Parental discretion is not unlimited, and parental choices may be overridden if they are deemed to endanger their children’s welfare or the public’s health. A case can be made that the COVID-19 pandemic is a public health crisis that makes parental refusals intolerable. If so, the proper moral response is not to empower adolescents to consent for themselves, but for state-enforced school vaccine mandates.

Now is the time for states to start preparing for the 2022 to 2023 school year.

The author thanks Walter Glannon, PhD, and Jodi Halpern, MD, PhD for thoughtful challenges to this article.

COVID-19

coronavirus disease 2019

HPV

human papillomavirus