Informed teens can make vaccination decisions themselves
Since the end of May, most provinces have allowed children aged 12 and older to receive the COVID-19 vaccine, eliciting mixed reactions from parents and doctors alike.
For parents, it represents a crucial fork in the pandemic road — whether to allow their children to be vaccinated. For doctors, it means navigating talks about the vaccine with teenagers whose parents are either hesitant or, in rare cases, refuse to let their children receive the vaccine.
Legally, minors in Canada don’t need an adult’s consent to receive a vaccine as long as they can show that they are mature enough to make decisions about their own healthcare, several experts have told Postmedia News.
“It’s about the individual, regardless of their age, being able to understand and appreciate the decision that’s before them,” said Dolly Mennadack, a clinical bioethicist at Holland Bloorview Kids Rehabilitation Hospital in Toronto.
The legislation, known in the U.S. and Canada as the mature minor doctrine, has been in place in Canada long before the COVID-19 pandemic; It was recognized by the Supreme Court of Canada in 2009.
Yet when Peel Region updated its vaccination guidance on May 20 to clarify that minors aged 12 and older don’t need parental permission, it was met with a wave of angry comments online.
“I don’t know who gave the authority for CHILDREN 12+ to consent on their own to get vaccinated, but I will be in touch with a lawyer in the morning to discuss the legality of this initiative and exactly who to include on this class action law-suite! This is insane,” tweeted Twitter user Maurice Zabanah.
“I’m 29 and I don’t even understand the benefits or risks of this vaccine (oh right, because clinical trials are still being done),” tweeted another.
Dr. Cora Constantinescu, who supports a vaccine confidence clinic that trains healthcare workers how to combat vaccine hesitancy in adults and children in Alberta, said that she encounters public backlash every time she has spoken on the issue.
“It’s a sensitive topic,” she said.
Constantinescu stressed that she and her colleagues, despite some public skepticism, do not try to influence
“If the teen understands the consequences of the treatment, is able to deliberate the information and has come to a very reasoned decision, then they have the capacity to make the decision.” Dr. Cora Constantinescu
teenagers to take the vaccine without parental consent. Rather, they play the role of educators, supporters and, when possible, encourage adolescents to include an adult, be it a parent or otherwise, when deciding to take the vaccine.
“We want parents to be involved and be part of the decision-making process all the time and we encourage kids to actually communicate it to their parents,” she said.
“But at the end of the day … if the teen understands the consequences of the treatment, is able to deliberate the information and has come to a very reasoned decision, then they have the capacity to make the decision,” she explained.
Federally, there is no age limit at which a child required parental consent to make decisions on aspects of their health care.
The only province to set one is Quebec, where children younger than 14 require the consent of the parent or guardian to make treatment decisions.
Which means that in most provinces, children as young as 12 are legally permitted to receive the vaccine without the consent of their parents or guardians.
Health-care providers are also not legally obliged to ask a young patient if they have told an adult about their decisions to receive the vaccine. “We want to make sure that the barriers (to accessing the vaccine) are very low,” said Dr. Lennox Huang, chief medical officer and vice-president of medical and academic affairs at the Hospital for Sick Children.
However, they are trained to take a more nuanced approach with a youth who has come to the clinic alone, versus a teenager who is accompanied by an adult. In the case of the latter, Menna-dack explained, “we’re able to see that that conversation (about the vaccine) has occurred and the interaction will involve the people who are present in the room,” she said.
For teens who come alone, it becomes the health-care providers’ responsibility to take those crucial introductory steps to assess how well the teen is supported and informed.
For one, it would mean asking questions to better understand the teen’s background and whether there may be an adult involved in the teen’s decision-making process.
“Really, the health-care provider would be looking to ask questions like ‘Are there people you have spoken to or would you like to speak to, can we offer you information about how to start that conversation with adults or caring adults in your life’,” she explained.
This first conversation, she said, allows the health-care provider to intuit “what the young person understands about the decision they’re making” and if, in some cases, there may be a reason “why guardian or parental involvement is not possible.”
The health-care provider, in those cases, when possible, could act as a mediator and support their young patient in efforts to communicate with their guardian or parent about the vaccine.
“That can be truly an important piece to uncover during this process,” Mennadack said.
While there may be efforts to involve an adult in the discussion, the health-care provider’s obligation, at the end of the day, rests with the young patient and ensuring that they themselves are informed and capable of understanding the benefits and risks of the vaccine, Huang said.
For Huang, that responsibility has extended beyond the hospital. Over the past few weeks, he and other Ontario public health officials and health-care experts have visited schools and held town halls to talk to parents and students about the COVID-19 vaccine. Digital and printed materials on the vaccine have also been handed out to Canadians either through email or at the clinics.
This means that by the time teens visit the clinic, they’re already familiar with the ins and outs of the vaccine, simplifying the conversation between doctor and patient. “So, our conversation is oftentimes very easy,” he said. “It’s straightforward.”
Deciding whether the teen in question is capable of informed consent is, contrary to public belief, not dependent on their age, Menna-dack said. Rather it’s their “emerging autonomy” — the individual’s life experiences, mental maturity and context that determine just how capable they are of making their own health-care decisions.
A teen, for example, may have more experience interacting with the health-care system, she posited, which could impact their familiarity with making medical decisions.
“Someone also can be affected by their maturity, and by their cognitive abilities,” she said.
One way a health-care worker could assess a youth’s capacity is by testing their knowledge of the vaccine and its effects: “What does the vaccine do, what are the potential side effects, what do you see as the benefits and risks of getting the vaccine,” Menna-dack listed as some examples of questions youth could be asked about the vaccine.
“We also would want to be ensuring that the young person knows where to get help,”she said, should they experience any mild or severe side effects from the dose.