Definition/Introduction

Adolescence is the critical transition from childhood to adulthood, characterized by unique biological, cognitive, emotional, and social changes.[1] In the United States, adolescence also marks the last stage in a minor's life before he or she transition's to legal adulthood at the age of 18 in most states. Minors legally cannot provide consent to their medical care and are not subject to the confidentiality protections under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[2] Parents or legal guardians usually have the authority to make medical decisions on behalf of minors and access their confidential medical information under the "best-interests standard" since, under the law, minors lack the cognitive maturity to be considered competent like adults.[3]

What is an emancipated minor?

As minors grow into adolescence, they begin to develop more mature cognitive skills and decision-making capacity, similar to adults.[4][5] If an adolescent needs to function as an adult before turning 18 years old or the legal age of majority, then they can pursue a legal status change to become an emancipated minor. Emancipated minors are free from parental or legal guardian control, and parents and legal guardians are also free from responsibility to the emancipated minor. More specifically, emancipated minors can legally consent to or refuse medical care without parental permission and notification.[6]

Issues of Concern

Emancipation laws in the US vary by state with little guidance from federal law. In general, minors who are married, on active duty status in the military, or living separately from their parents or legal guardians and independently managing their own financial affairs are considered emancipated.[7] Minors may or may not require a formal court declaration of emancipation to change their legal status.[6] Emancipated minors are also legally responsible for covering the financial cost of their medical care.[6] Of note, there are other circumstances besides emancipation, where minors can consent to medical care without parental permission. In general, exceptions to parental consent when treating minors can be categorized as follows: emancipation, “mature minor” doctrine, federally regulated public health services, and state-regulated public health services.

The “mature minor” doctrine legally recognizes the medical decision-making capacity of adolescents, even though they are still minors under parental or legal guardian control. Very few states recognize a version of the “mature minor” doctrine. Minors usually 12 years or older who demonstrate adequate cognitive maturity and capacity to understand the risks, benefits, alternatives, and likely outcomes of medical evaluation and treatment are authorized to provide consent or refuse without parental permission.[7][8] States with a mature minor legal exception may allow certain mature minors to provide consent broadly but usually restrict that authority based on age, parental availability, and sensitive clinical situations.[6]

Emergency medical care also presents another exception to the necessity of parental or legal guardian consent to treat a minor. Current federal law under the Emergency Medical Treatment and Labor Act (EMTALA) mandates that a medical screening exam must be performed on all individuals, including minors, presenting to any federally funded emergency department regardless of consent and ability to pay.[9] If an emergency medical condition is identified in an unaccompanied minor during the medical screening exam, healthcare providers must provide life or limb-saving treatment without delay from seeking and securing parental consent. Health care providers are legally protected in this circumstance by the “emergency exception rule” or “doctrine of implied consent,” which assumes that any reasonable parent or legal guardian in an emergency would consent to medical treatment for their child.[2][9] If no emergency medical condition is identified in an unaccompanied minor during the medical screening exam, EMTALA no longer applies.  Health care providers must either obtain parental consent to treat the minor or identify if the minor can receive treatment without parental consent based on their legal status or type of medical service they seek.[2]

In general, adolescents can consent to specific medical services that provide an important public health benefit without parental permission or notification.[7] Some of these services are federally funded and consistently available in most states, including the preventative, contraception, and reproductive health services provided by the Title X Family Planning Program of the Public Health Service Act.[2] The US Supreme Court has upheld the constitutional right of minors to choose abortion but has also upheld the state’s right to impose requirements for parental involvement as long as “adequate provision for judicial bypass” is available for minors where parental involvement is not in their best interest.[10] The following is a brief list of medical services that minors may consent to in many states without parental permission and in some cases without parental notification:

• Rape or sexual assault services
• Contraception services
• Sexually transmitted infections
• Prenatal care
• Abortion [10][11]
• Pediatric care for children of minors
• Substance use disorder treatment [12][13]
• Mental health treatment [12]
• Immunizations [14]

Clinical Significance

All healthcare providers (i.e., nurses, physicians, and prehospital healthcare providers) need to be aware of and understand the various exceptions when a minor can be medically evaluated and treated without the presence or consent of a parent or legal guardian. The American Academy of Pediatrics (AAP) recommends that health care providers support adolescents' growing autonomy and transition to adulthood by including their viewpoint and consent in a shared, family-based decision-making model. Providers have a duty to serve the pediatric patient's best interest and not necessarily the parents' desires. Parental consent should be considered a responsibility that supports the minor's best interests and preserves a family's interests, rather than a parent's right to express their own autonomous choices.  Reframing parental consent as parental responsibility may help clinicians minimize conflict during difficult medical decision-making in a child's health care.[7]

Nursing, Allied Health, and Interprofessional Team Interventions

All health care providers involved with the medical care of minors should learn more about their state’s laws regarding emancipated minors, mature minor exceptions, and specific medical services that do not require parental permission to best serve their adolescent patients.[1][2] In states that do provide a mature minor exception, health care providers should develop a set of protocols that outline a process for assessing the minor’s maturity and decision-making capacity as well as legal documentation guidelines to protect against liability during litigation.[8] State-specific laws and policies on teenage reproductive health are available at the Guttmacher Institute. Details regarding adolescent consent and confidentiality rules are available at the Center for Adolescent Health and the Law (ww.cahl.org).

Furthermore, health care providers are urged by the American Medical Association and AAP to make all efforts to respect the adolescent’s privacy from their parents or legal guardians with a clear explanation that confidentiality is conditional in certain circumstances.[2][10] However, the conditional nature of confidentiality in adolescent health care does not apply when working with an emancipated minor or a minor accessing medical services that do not require parental consent or notification.  Health care providers need to make extra efforts to protect adolescents' confidentiality in electronic medical records and insurance billing in these exempt circumstances.[1]