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A 16 year old is in your office. She is scared because she has heard that measles is making her comeback, but she knows that she has never been vaccinated. Now she wants you to give her the measles-mumps-rubella (MMR) vaccine, even if her parents do not want her to get one. What should you do?
Such a situation may become less rare as social media-savvy teenagers read about peers who challenge their parents' beliefs about what appears to be a growing number of previously eradicated disease outbreaks, including measles, which strikes parts of New York. City and state and parts of Oregon and Washington.
For the clinician, deciding to vaccinate a minor without the consent of their parents is a difficult situation – a situation that is not resolutely regulated by federal law or ethical standards.
Although Congress has an upcoming hearing on vaccine exemptions, and US Food and Drug Administration Commissioner Scott Gottlieb told CNN that the federal government may need to step in, the laws in force in the state govern the age of consent for medical procedures, including vaccination. The oath of Hippocrates dictates: "First, do no harm."
Yet the situation is blurry, say the ethicists. "There is no clear legal indication about when the determination, desire or lack of treatment of a minor differ from the wishes of his custodial parents," he said. Zack Buck, JD, MBE, Adjunct Law Professor at the Law School of the University of Tennessee, Knoxville. . "You are so far from the paved surface here," he says Medscape Medical News.
In this situation, "the law leaves it to each doctor to determine what kind of action is appropriate," he said. However, Buck said the courts would not be likely to support a doctor who overrides a parent's wish to vaccinate a minor – unless it can be claimed that there is a risk imminent danger by not getting vaccinated.
"Parents have a lot of authority in making medical decisions under the age of 18," said Art Caplan, PhD, a regular contributor to Medscape., and Drs. William F. and Virginia Connolly Mitty Professor of Bioethics and Founding Director of the Division of Medical Ethics of the NYU School of Medicine in New York.
"Unless there is a clear and imminent danger of death, the authority of his parents will probably be canceled by no one," Caplan said. Medscape Medical News.
More teens question parents
The actions of a teenager seem to have provoked a small conflagration among teens and young adults who might have wondered whether or not they should be vaccinated despite their parents' position at the school. vaccination.
Ethan Lindenberger, 18, of Norwalk, Ohio, has become a reference in social media and mainstream media since the first appearance of his article on February 6 To get away.
Ethan Lindenberger (Photo courtesy of Ethan Lindenberger)
Lindenberger, whose mother believes vaccination is the cause of autism, has been doing research on immunization for several years. At age 18, a friend told him that he could be vaccinated without his parents' permission. But he was still hesitant, he says Medscape Medical News. He then discovered that he would need to be vaccinated in order to be admitted to college. His mother, Jill Wheeler, told him that he could withdraw under state laws allowing derogations for religious or medical reasons – as she had done to keep him in high school.
According to the National Conference of State Legislatures, the 50 states require specific vaccines for students, but each state grants exemptions for medical reasons. Almost all states grant religious exemptions and 17 states allow philosophical exemptions for personal, moral or other beliefs.
Lindenberger decided that vaccination was too important to be able to not participate. He spoke with the family doctor and discovered that he had received a tetanus shot at the age of 2 years after an injury and a vaccine against hepatitis B – although his mother denied having received it and told him that it had to be done. without his consent, Lindenberger said.
He said that his mother was not an anti-medicine, but that "parents should be trusted more than doctors."
Wheeler continues to be anti-vaccinations, as shown by his Facebook posts. She believes that doctors are trained to say that vaccines are good and do not entertain alternative opinions – this "takes away legitimacy, in her eyes," Lindenberger said.
"I think it's ridiculous," he said. "To say that the medical community is a source of mistrust, is that you disagree with them on a subject – it's a bit silly."
His family doctor directed him to the health department for his vaccines, where he received vaccines against influenza, HPV 1, hepatitis A, hepatitis B and tetanus in December. He will receive the MMR vaccine, polio, chickenpox and HPV 2 later in February.
Lindenberger played an active role in reporting and on February 13 organized a Reddit AMA ("Ask Me Anything") on her decision to be vaccinated against her mother's wishes – following a first publication on Reddit in November. when he first approached the subject asking for advice on getting vaccinated.
The Ohio teenager has since become an inescapable source for hundreds of others who are considering the same thing, Lindenberger said. They are mainly young people aged 15 to 18, but also people in their twenties, many of whom live at home, he said.
"Many of them said that I am in a similar situation and that it sucks," Lindenberger said. Medscape Medical News. Most of them feel stuck – they believe the vaccines are good, but they feel that they can not go against their parents.
He advised his peers to familiarize themselves with the consent laws in force in their country and to see if they could be vaccinated without permission from their parents. If not, "try to talk to your parents if you can, try to convince them, show them the evidence, explain to them that you might not agree, but that you still love them." Or, they can wait until they are 18 years old or until they have moved out.
"But you also have to understand that at this point, you are really postponing extremely important medical procedures," Lindenberger told people looking for advice. He adds, "If you think that vaccines are as important as me, you will try to get vaccinated as soon as possible."
The effect of Lindenberger's fame on other teenagers is not clear. However, on February 18, CTV Vancouver, a local television channel, reported an upsurge of teenagers seeking immunizations against the wishes of their parents in Vancouver – which is experiencing an active measles outbreak.
What can clinicians do?
Should doctors approve applications for vaccination of minors?
Abigail English, JD, of the Center for Adolescent Health and Law, Chapel Hill, NC, recently broached the subject pediatrics. "The question of when adolescents can give consent for their own vaccination depends on the badysis of several factors: the age and ability of the adolescent, the state in which the "Teenager seeks to be cared for, the legal status of the adolescent, the type of health and the illness for which the vaccination is administered," she wrote with their colleagues.
As a general rule, the laws on the consent of minors allow them either to give their consent according to their status (married, adult, pregnant, etc.) or the services they seek. "Ultimately, providers and public health officials in each state must understand the laws and interpretations in effect in their state," wrote the Englishman. She indicated that information on the minor consent laws was available from the Center for Adolescent Health and the Law and the Guttmacher Institute.
Caplan and Buck both said that a doctor could decide that it was in the best interests of the child to give the vaccine, even medically.
But if state law is not on the doctors' side, it may open them up to court challenge, Buck said. "It depends here on whether or not the parents feel that a doctor who refuses to follow through on their wishes is bending in a way that is worth asking for legal compensation," he said.
He advises clinicians to "document, document, document". It would be difficult for parents to prove that they have compensable damages, Buck said.
Even if the damages are not awarded, having a legal judgment against a clinician is obviously not good, he said. A doctor who is vaccinated may not be paid and may be reprimanded by the state medical commission for violation of consent or lack of reasonable and medically necessary treatment.
Clinicians confronted with minors should request a family reunion, "be ready to provide all the evidence of vaccine safety" and report any outbreak or risk to that child, Caplan explained.
If that does not work, "try to get a court order"; this would allow the doctor to reverse the parents' decision, he said.
Caplan and Buck also stated that clinicians could inform social services of the child's desire to be vaccinated, but they both acknowledged that the absence of risk of imminent harm was likely to not be met. attract a lot of attention.
"I would just try to persuade parents again and again and again, that's what the child wants, that's what the kid needs," Caplan said.
Caplan disclosed the following relevant financial relationships: has been a director, officer, partner, employee, advisor, advisor or trustee of the Johnson & Johnson Addictions Experts Group (unpaid position); serves as author and advisor for Medscape.
Buck has not revealed any relevant financial relationship.
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