Decision-Making for Adolescents at the Margins of Legal Maturity - Is There a Better Way?

Johan Bester, MBChB, PhD, HEC-C – Saint Louis University School of Medicine

Abstract: The principle of autonomy describes how adults with established decision-making capacity have the right to choose how they receive or deny their medical care. In the United States, adolescents legally become adults once they reach their state’s age of majority, where the typical adolescent then inherits their right to autonomy. However, there are reasons to doubt whether such a binary approach to being considered one’s own decision-maker is ethically appropriate. Some adolescents may develop advanced decision-making capacity before the age of majority, and some adolescents may lack advanced decision-making capacity after the age of majority. This paper-in-progress aims to revisit the current standard for granting pre-adult adolescents and adolescent-adults with decision-making capacity by investigating how different factors influence the developing maturity of adolescents. This paper will review various factors that may influence development of decision-making capacity among adolescents, some of which may hasten and some which may delay full-fledged autonomy. This includes factors like being emancipated status and experience with continued treatment, which are associated with increased psychological maturity. Additionally, the paper will review research on the variability of three core factors that contribute to decision-making capacity, including prefrontal cortex development, harboring a stable value system, and experience with making critical decisions. The paper will then review the implications of these for how we approach decision-making in adolescents around the age of majority and propose possible alternatives for determining decision-making capacity in adolescents other than with age alone.

Keywords: Developing autonomy, Medical decision-making for adolescents, Decision-making capacity