A 16-year-old is in your office. She’s scared because she’s heard measles are making a comeback, but she knows she’s never been vaccinated. Now she wants you to give her the measles-mumps-rubella (MMR) shot, even though her parents don’t want her to get one. What should you do?
Such a situation may become less rare as social media-savvy teens read about peers who are questioning their parents’ beliefs in the face of what seems to be a growing number of previously eradicated disease outbreaks, including measles, which is hitting parts of New York City and state and parts of Oregon and Washington.
For the clinician, deciding whether to vaccinate a minor without a parent’s consent is a tough situation — one that is not squarely addressed by federal law or ethical standards.
Although Congress has some upcoming hearing on vaccine exemptions, and US Food and Drug Administration Commissioner Scott Gottlieb, MD, told CNN that the federal government might have to step in, current state laws govern age of consent for medical procedures, including vaccination. The Hippocratic Oath dictates, “First, do no harm.”
Still, it’s a hazy situation, ethicists say. “There’s no clear legal guidance on when a minor’s determination or desire for treatment or lack of treatment differs from their custodial parents’ wishes,” said Zack Buck, JD, MBE, associate professor of law at the University of Tennessee College of Law, Knoxville. “You’re so far off the paved surface here,” he told Medscape Medical News.
In this situation, “the law leaves it up to each physician’s guiding light to mete out what type of action is appropriate,” he said. However, Buck said that courts aren’t likely to back a physician who overrides a parent’s wishes to vaccinate a minor — unless a case could be made that there’s an imminent risk of danger in not being vaccinated.
“Parents have a lot of authority in the medical decision-making of anybody under 18,” said Art Caplan, PhD, a frequent contributor to Medscape, and the Drs. William F. and Virginia Connolly Mitty Professor of Bioethics and founding head of the Division of Medical Ethics at NYU School of Medicine, New York City.
“Unless there is a clear and imminent danger of death, the authority of the parents is not likely to be overridden by anybody,” Caplan told Medscape Medical News.
More Teens Questioning Parents
The actions of one adolescent seem to have ignited a small conflagration among teenagers and young adults who may have been questioning whether they should be vaccinated in spite of their parents’ stance against vaccination.
Eighteen-year-old Ethan Lindenberger, from Norwalk, Ohio, has become a social media and mainstream media sensation since his story first appeared on February 6 in Undark.
Ethan Lindenberger (Photo courtesy of Ethan Lindenberger)
Lindenberger, whose mother believes that vaccination causes autism, had been researching vaccination on his own for several years. At age 18, a friend told him he could get vaccinated without his parents’ permission. But he was still hesitant, he told Medscape Medical News. Then he discovered he would need to be vaccinated to gain admission to college. His mother, Jill Wheeler, told him he could opt out under state laws that permit waivers for religious or medical reasons — as she had done to keep him in high school.
All 50 states require specific vaccines for students, but every state grants exemptions for medical reasons, according to the National Conference of State Legislatures. Almost all states grant religious exemptions, and 17 states allow philosophical exemptions for personal, moral, or other beliefs.
Lindenberger decided immunization was too important to opt out. He talked with the family physician and discovered that he had been given a tetanus shot at age 2 after an injury and a hepatitis B vaccine at some point — although his mother denied he’d ever gotten the latter shot and said it must have been done without her consent, Lindenberger said.
He said his mother is not antimedicine, but that “parents are to be trusted more than doctors.”
Wheeler continues to be antivaccinations, as her posts on Facebook show. She believes that physicians are trained to say that vaccines are good and don’t entertain alternative views — that “takes away the legitimacy, in her eyes,” Lindenberger said.
“I think that’s ridiculous,” he said. “To think that the medical community is to be distrusted because you disagree with them on one topic — it’s a little silly.”
His family physician referred him to the health department for his vaccines, where he received the influenza, HPV 1, hepatitis A, hepatitis B, and tetanus shots in December. He will be receiving the MMR, polio, chickenpox, and HPV 2 later in February.
Lindenberger has been an active presence in news reports, and hosted a Reddit AMA (“Ask Me Anything”) on February 13 entertaining questions about his decision to be vaccinated against his mother’s wishes — a follow-up to an initial posting on Reddit in November, when he first broached the subject asking for advice on getting vaccinated.
The Ohio teenager has since become a go-to source for hundreds of others who are contemplating the same thing, said Lindenberger. It’s mostly 15-to-18-year-olds, but also people in their 20s, many living at home, he said.
“A lot of them said I’m in a similar situation and it sucks,” Lindenberger told Medscape Medical News. Most of them feel stuck — they believe that vaccines are good, but they feel like they can’t go against their parents.
He has advised his peers to become familiar with consent laws in their states and see if they can be vaccinated without their parents’ permission. Otherwise, “try to talk to your parents if you can, try and convince them, show them the evidence, explain that you might disagree, but you still love them.” Or, they can wait until they are 18 or until they have moved out.
“But you also have to understand that at that point you’re really postponing medical procedures that are extremely important,” Lindenberger said he tells those seeking advice. He adds, “If you think vaccines are as important as I do, you’ll try to get vaccinated as soon as possible.”
It’s unclear what effect Lindenberger’s high profile is having on other teens. But CTV Vancouver, a local television station, on February 18 reported a surge in teens seeking vaccinations against their parents’ wishes in Vancouver — which has an active measles outbreak.
What Can Clinicians Do?
Should physicians approve minors’ requests for immunization?
Abigail English, JD, from the Center for Adolescent Health & the Law, Chapel Hill, North Carolina, recently addressed the topic in Pediatrics. “The question of when adolescents may give consent for their own vaccination depends on an analysis of several factors: the age and capacity of the adolescent, the state in which the adolescent is seeking care, the legal status of the adolescent, the type of health care, and the disease for which vaccination is being administered,” she and colleagues wrote.
Generally, consent laws for minors either allow them to give consent on the basis of their status (married, mature, pregnant, etc) or the services they are seeking. “Ultimately, providers and public health officials in each state must understand the laws and interpretations in force in their state,” English wrote. She noted that information about the minor consent laws is available from the Center for Adolescent Health & the Law and the Guttmacher Institute.
Caplan and Buck both said that a physician may decide that ethically — or even medically — it is in the best interest of the child to give the vaccination.
But if state law is not on the doctor’s side it can open them up to legal challenge, Buck said. “It depends here whether or not the parents feel that a doctor overriding their wishes is overstepping in a way that’s worth seeking legal compensation for,” he said.
He advises clinicians to “document, document, document.” It would be difficult for parents to prove they have compensable damages, Buck said.
Even if damages are not awarded, having a legal judgement against a clinician is obviously not good, he said. A physician who vaccinates might not get paid, and could receive a rebuke from the state medical board for violating consent or not providing reasonable and medically necessary treatment.
Clinicians faced with minors should ask for a family meeting and “be ready with all of the evidence about the safety of vaccines,” and point out any nearby outbreaks or risks for that particular child, Caplan said.
If that doesn’t work, “try to get a court order”; that would allow the doctor to override the parents’ decision, he said.
Both Caplan and Buck also said that clinicians could notify social services about the child’s desire to be vaccinated, but both acknowledged that with no risk of imminent harm that might not likely get much attention.
“I would just try to persuade the parents again and again and again that’s what the kid wants, that’s what the kid needs,” Caplan said.
Caplan has disclosed the following relevant financial relationships: served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position); serves as a contributing author and advisor for Medscape.
Buck has disclosed no relevant financial relationships.
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