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In Both Sides Now, author and ethicist Leslie Cannold presents two sides of an argument, and then it’s over to you: what do you think is true, and what do you think Cannold really believes?

Today she asks: when young people want to make serious and irreversible medical decisions, should good parents understand the borders of consent and say no? Or has autonomy correctly replaced paternalism as the proper guide to medical decision-making?

For

If an adult has capacity, then decisions about medical interventions are usually straightforward. Once a free and informed consent is obtained, the therapy — both legally and morally — can proceed.

There are two critical characteristics of a consent that is free and informed. They are: that it is an intentional authorisation given by a person, with substantial understanding of the advantages and disadvantages of the proposed procedure, and in a context where there is a substantial absence of control by others. 

Children, to state the obvious, are not adults. Young children have no ability to make a decision about medical intervention in a free and informed fashion and so must rely on parents or guardians to make decisions in their best interest.

Young people between the ages of 11 and 17 may be able to make decisions to accept or refuse medical interventions for themselves, but this will vary with the complexity and weightiness of the decision-making task.

Accepting an aspirin and refusing a life-saving blood transfusion, in other words, are different. The idea, articulated in England’s landmark Gillick case, is that if a minor can make a reasonable assessment of the advantages and disadvantages of the treatment proposed, they are grown up enough to make that decision for themselves.

In practice, the bar is often higher. In particular for medical decisions that have serious implications for the child’s future and can’t be reversed. Teenagers who have consented to sex may be deemed mature enough to have an abortion, but even long-time sufferers of childhood cancer may be compelled to accept standard medical treatment, regardless of whether they — even with the support of their parents — wish to refuse.

This is tough but fair. Both courts and parents understand that minors are not adults but in the process of becoming them. In particular, young people are still in the process of accumulating and consolidating the identity, experience and wisdom they need to recognise decisions that could have a profound impact on their future.

Such immaturity is the definition of adolescence and entirely normal, but so is the impulse of adults to avoid their children finding themselves stuck with a life-altering choice they’ve come to regret.

This is why good parents take their moral obligations to kids so seriously. They have a duty to give or — where required — refuse permission for medical interventions not in their child’s best interests; to deliver their child safely to adulthood so they can make autonomous choices about their own lives themselves.

Against

The responsibilities parents have are indeed awesome. Foremost amongst them is to listen to their children and heed what they say.

The paternalism of the “for” argument is staggering; a throwback to the days when authorities like doctors, lawyers, judges, parents and cops were put in charge of every decision that mattered for everyone. Ah, for the halcyon days of backyard abortions and gays in closets, not to mention the charming practice of surgically assigning intersex children a gender not long after they were born — “for their own good”, of course.

The truth is that no one knows better what’s best for a person than that person themselves. Even if they are a young person. Who can forget the case of 16-year-old Starchild Abraham Cherrix who, when his Hodgkin’s disease returned after just a few months of remission, refused any further chemotherapy because of how weak and sick it made him the first time.

While the state successfully sued the parents for neglect, the ruling was overturned by a higher court and Cherrix survived — with the help of alternative treatments — to celebrate his 18 birthday and emancipation from interference in his medical treatment decisions by the state.

As Cherrix’s case showed, young adults can often meet the “mature minor” standards laid out in Gillick. Indeed, according to one study, the capacity of most 14-year-olds to give informed consent was indistinguishable from adults. The data also shows that the psychological outcomes are better for transgender youth who have more gender-affirming interventions compared to those who have less or none.

Ditto for women who have labiaplasty, particularly for those who had physical/functional reasons for pursing the procedure in the first place.

Facts like these matter. They speak to the unnecessary costs — even cruelty — of delaying irreversible interventions like surgery. They also provide reassurance to parents worried about their child making a decision she might eventually regret.

Over the course of the 20th century, autonomy replaced paternalism as the proper legal and moral framework to guide medical decision-making. Today, it’s patients, not doctors, who are seen to know best. There’s good evidence that this truism applies to young people too.

Which side do you think Cannold sits on? And what do you believe? Send your thoughts to [email protected] with Both Sides Now in the subject line.

Peter Fray

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