For pediatricians, how to respond to vaccine hesitancy is a long-standing ethical dilemma. “It has long been part of our profession. Finding positive approaches to encourage vaccination has traditionally been viewed as good practice, over shaming or negative lines of questioning,” says Jeanne Delgado, MD, MPH, an assistant professor of clinical pediatrics at Keck School of Medicine of USC in Los Angeles.
After the COVID-19 vaccine became available, numerous studies examined the characteristics of individuals who were “anti-vaxxers” or “slow adopters.”1,2 “While we agreed it was important to learn who these hesitant groups were, we also wanted to understand what positive motivators could influence them to be vaccinated,” says Delgado.
Delgado and colleagues conducted a study of the most vaccine-positive group they knew of: those in the healthcare field. The researchers interviewed 21 vaccinated healthcare workers and their vaccinated adolescent children in Southern California.3
Overall, parents and adolescents largely supported self-consent for COVID-19 vaccination, with the caveat that parents could discuss the decision with the adolescent beforehand. Adolescents who supported self-consent laws described negative potential outcomes that could occur in the absence of the right to self-consent, such as friends not getting vaccinated. Some parents highlighted the negative potential outcomes if adolescents were given this right, such as their child choosing not to get vaccinated. Parents did express concerns that adolescent self-consent laws could lead to missed opportunities for parents and adolescents to engage with healthcare providers together. However, those parents also talked about ways that parents could remain part of the process and assist adolescents in making decisions.
“Parental involvement in healthcare decisions will remain important for adolescents, but vaccinations are critical for public health and are considered a low-risk medical decision that adolescents should be developmentally able to make. Empowering adolescents to be able to self-consent to vaccinations could equip them to be more informed and invested in their own health, lead to discussions that change family-level decisions, and increase population-level vaccination rates,” offers Katia Bruxvoort, PhD, MPH, another of the study authors and an adjunct investigator at Kaiser Permanente Southern California.
In some states, adolescents are allowed to consent to mental healthcare, substance abuse treatment, or sexual and reproductive health. Some state laws allow adolescents to receive certain vaccinations and other preventive healthcare.4 “Given that adolescents’ educational performance, social interactions, and even familial financial responsibilities or caretaker roles were all impacted by COVID, some would say they should be able to decide on their vaccination status,” observes Delgado. “These findings continue the conversation on adolescent medical autonomy.”
Clinicians caring for hospitalized adolescent patients face some challenging ethical dilemmas involving consent. “Parents and healthcare teams must work with adolescent patients to support their developing autonomy, while also protecting their long-term autonomy,” says Annie B. Friedrich, PhD, HEC-C, an assistant professor in the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin. Clinicians strive to empower adolescents to make their own healthcare decisions in light of what matters most to them. At the same time, clinicians must establish appropriate constraints on decision-making authority — such as limiting the adolescent’s authority to make a decision if it leads to death or significant harm. Emancipated minors (those deemed by the law to be independent from their parents or legal guardians) are allowed to make their own healthcare decisions. “Adolescents with chronic conditions or life-limiting illnesses who have greater insight into their disease are also more likely to be given greater decision-making authority,” says Friedrich.
Decision-making capacity is another important ethical consideration. “Just because adolescents might be able to demonstrate capacity at the level of adults does not mean that the medical team should give them authority to make healthcare decisions,” says Friedrich. The need to consider long-term interests over short-term interests often comes into play. Friedrich recently consulted on a case where an adolescent’s decision-making capacity was the central issue. The patient was refusing nutrition, in the context of atypical anorexia nervosa. The clinical team questioned if it was ethically justifiable to restrain the patient to provide necessary nutrition, and requested an ethics consult. Friedrich attended several meetings with the healthcare team and the parents, who were the patient’s legal decision-makers. Ultimately, it was determined that the patient could not appreciate the consequences of the decision to refuse nutrition — which were severe health complications and potentially death. Ethicists made these recommendations:
• If clinicians tried all other less-restrictive options, but the patient continued to refuse nutrition (either by mouth or via nasogastric tube feedings), the medical danger was imminent and legitimate.
• If the legal decision-makers provided assent to the necessary treatment, restraints may be ethically justified.
• The clinical team should strive to communicate the plan clearly with the patient.
• Clinicians should provide the patient every opportunity to make the choice to eat without restraints.
• The clinical team should set a clear end goal, since restraints are not a viable long-term option.
Based on these recommendations, the medical team used appropriate restraints to ensure the patient received proper nutrition, and arranged for the patient to be transferred to a facility that could adequately address the patient’s underlying mental health issues.
Ethicists emphasized the need to include the adolescent patient in conversations and decision-making to the greatest extent possible. “There is a need to balance their needs and preferences within the medical context of what is feasible, reasonable, and most likely to bring about the greatest good for the patient and family,” says Friedrich.
- Kim S, Willis E, Wehlage S, et al. COVID-19 vaccine hesitancy and short-term and long-term intentions among unvaccinated young adults: A mixed-method approach. BMC Public Health 2022;22:2030.
- Su Z, Wen J, Abbas J, et al. A race for a better understanding of COVID-19 vaccine non-adopters. Brain Behav Immun Health 2020;9:100159.
- Delgado JR, Mansfield LN, Bruxvoort K, et al. Adolescent self-consent for COVID-19 vaccination: Views of healthcare workers and their adolescent children on vaccination autonomy. J Adolesc Health 2023;72:674-681.
- Mihaly LK, Schapiro NA, English A. From human papillomavirus to COVID-19: Adolescent autonomy and minor consent for vaccines. J Pediatr Health Care 2022;36:607-610.
