The Mature Minor Doctrine: Should a Mature Minor Have the Right to Refuse Life-Sustaining Treatment in New York?

Mike Telfer, Government Law Review Member

Background

          In the area of medical decision making, minors “are presumed incompetent, and thus require the aid of parents or guardians to assist in the decision-making process.” [1]  Under common law, doctors were required “to obtain parental consent before treating a minor” and were liable for battery if a minor was treated without parental consent.[2]  The mature minor doctrine is the exception to the common law and essentially transforms a minor into a competent adult for medical decision making purposes.[3]  For the doctrine to apply, a minor must “demonstrate a sufficient level of maturity . . . to have their choices respected independent of third parties.”[4] 

          New York does not have a statutory law creating a mature minor doctrine or any case law recognizing its application in the state.  One lower court has refused to adopt the rule, holding that the “legislature or the appellate courts [should] take a hard look at the ‘mature minor’ doctrine and make it either statutory or decisional law in New York State.”[5]  While the courts in the State, like the Supreme Court, have recognized the right of competent adults to refuse life-sustaining treatment,[6] New York does not currently recognize the right of anyone under eighteen who is not married or a parent to refuse life-sustaining treatment by himself.[7]  When a minor is not a parent or married, the State or a minor’s parents can overrule a minor’s decision to refuse life-sustaining treatment if a court finds the minor’s decision is not in his best interest.[8]

Suggestions for the New York Legislature

          “There is nothing in the [U.S.] Constitution about children . . . [or] minors,” but their absence does not mean their rights are nonexistent [9] as “constitutional rights do not mature and come into being magically only when one attains the state-defined age of majority.” [10]  A minor who has proven competency through maturity should have the right to refuse life-sustaining medical treatment.  The rights of teenagers who have proven their understanding of the risks and benefits of treatment should not be infringed because they are two or three years younger than their peers at eighteen who are able to make the decision without interference from the State or their parents.  Thus, the New York Legislature should adopt the mature minor doctrine to clarify the rights of minors to refuse life-sustaining treatment. 

          New York should adhere in some form to Tennessee’s adoption of the Rule of Sevens to determine a minor’s maturity so that any minor under the age of seven would not be able to refuse treatment and a minor between seven and fourteen would be presumed to be incompetent to refuse treatment pending other evidence. [11]  Minors older than fourteen would be presumed to have capacity to refuse treatment,[12] but a doctor would have to support this presumption with clear and convincing evidence of the existence of certain factors to decide if a minor was in fact mature to refuse treatment.[13]  The following factors should be considered together and given equal weight to determine if a minor is mature:

age, . . . experience, education, . . . [the] degree of maturity or judgment obtained by the minor, . . .the conduct and demeanor of the minor at the time [of the decision to refuse treatment], . . . the totality of the circumstances, the nature of the treatment and its risks or probable consequences, and the minor’s ability to appreciate the risks and consequences. [14]

          Once a doctor determines whether a minor is mature under the standard, the parents or the minor should be able to appeal the doctor’s determination.  A judge should appoint a guardian ad litem to speak to the minor and collect information about the minor in accordance with the above factors.  The guardian should then report the findings to the judge, which the parents may attempt to rebut.  The judge, using the evidence submitted by both parties, should then be able to make an informed ruling on the maturity of the minor.

          Opponents of the doctrine in New York could argue the State has a public policy of valuing life and that the State must to act to protect a minor’s life which could be jeopardized with a short-sighted decision.[15]  This claim can be refuted as once the minor is deemed mature, the minor will be considered equal to an adult in their ability to refuse treatment thus removing the State’s need to protect the minor.  In addition, the public policy of the State will not be lost, as there will be two checks on the minor’s decision, one from a doctor and one from a judge who will check any error in a doctor’s decision.  Furthermore with a standard requiring clear and convincing evidence, maturity will be proven by strong evidence which will preserve the policy of valuing life for minors who cannot prove maturity. 

          Opponents may also argue that the State has four interests: (1) preservation of life, (2) protecting interests of third parties, (3) prevention of suicide, and (4) to maintain the ethical integrity of the medical profession.  The Court of Appeals has already held these four factors will not outweigh the right of a competent adult to refuse life-sustaining treatment.[16]  As a result these factors should not affect the rights of mature minors to refuse the same kind of treatment as they would be acting with the same decision making ability as competent adults.

          In evaluating the preservation of life interest in Fosmire v. Nicoleau, the Court of Appeals held that the State can act when “[an] individual’s conduct threatens injury to others,” such as refusing a vaccine which could harm the public.[17]  However, the court held that when an individual’s conduct will harm only themselves such as refusing life-sustaining treatment, it would be inconsistent with the “primary function of the State to preserve and promote . . . the personal autonomy of the individual” to interfere with one’s decision which will affect his or her own life or health only.[18]

          In regards to protecting the interests of third parties, the court in Fosmire also held that the fact a patient is a parent of a minor child does not affect his or her right to refuse treatment.[19]  This is the vice-versa situation of cases involving mature minors.  If a minor was married, pregnant, or a parent, then a parent’s opinion would not affect a minor’s decision.  Because the State allows parents to refuse treatment at the expense of their children, it should honor the minor’s mature decision at the expense of their parents’ opinions as it is the minor’s future, not the parents’ future which will be affected by a minor’s decision.[20] 

          Furthermore, the court held that “merely declining medical care, even essential treatment, is not considered a suicidal act” and that requiring an individual to submit to life-sustaining medical treatment is neither mandated by statute nor “required at common law.[21]  Thus minors will not be committing suicide by refusing treatment as they will be allowing the disease they are afflicted with to progress to the point where death will come sooner than without treatment. 

          Allowing mature minors to refuse life-sustaining treatment will not harm the medical profession.  The Court of Appeals held in Matter of Storar that “a doctor cannot be held to have violated his legal or professional responsibilities when he honors the right of a competent adult patient to decline medical treatment.”[22]  As competent adults can already refuse treatment, the medical profession will not change by allowing mature minors to make the same decisions. 

          Giving the right to refuse life-sustaining medical treatment to mature minors is not a vast change from current law as the State acknowledges some instances where minors can decide medical treatment on their own.  Currently, the State “permit[s] [all] minors to consent to . . . treatment for substance abuse . . . [and] sexually transmitted diseases.”[23]  The State also allows the waiver of parental consent when time to “secure consent” would pose a risk to the minor’s health or life.[24]  Furthermore, New York’s Do Not Resuscitate (DNR) statute recognizes the intent of the State to involve minors in decisions involving their refusal of life-sustaining treatment, because once it is determined a minor has capacity, a doctor must obtain both the minor’s and the parent’s consent before issuing a DNR order.[25] 

          The Court of Appeals decision, In re Seiferth, also supports the adoption of the mature minor doctrine in New York.  In Seiferth, the court rejected a County Health Department’s petition to force a “fourteen-year-old boy with cleft palate and harelip” to have surgery to repair his condition.[26]  The court based its holding on the fact there existed “no present emergency,” the lower court had found the minor “acquired convictions of his own” and shown maturity in his decision, and the minor’s cooperation would be needed for the surgery and to repair his speech which was affected by his condition.[27]  Alhough Seiferth did not concern the right to refuse life-sustaining treatment, it is a precedent for allowing minors to refuse medical treatment even though the State disagrees with their choice, and illustrates the State’s recognition of the need to include minors in medical decision making. 

          The New York Legislature and the Court of Appeals have thus showed that the State “did not intend there to be an absolute . . . age barrier prohibiting minors from . . . [making decisions involving their own] medical treatment” as the State has given more decision making authority to minors than the common law allowed. [28]  Thus, the legislature should allow mature minors to refuse life-sustaining treatment as the next step in giving minors more medical decision making rights.

Conclusion

          By adopting the mature minor doctrine and allowing mature minors the right to refuse life-sustaining treatment, the New York Legislature would recognize that maturity is an appropriate standard for making medical decisions and that age should not always be the final determinant.  As a result, the State would allow mature minors to control their fate, die with dignity if they choose, and know their final decisions will be respected by both the State and their parents.

Edited by Joe Slater and Stephen Dushko


[1] Jonathan F. Will, My God My Choice: The Mature Minor Doctrine and the Adolescent Refusal of Life-Saving or Sustaining Medical Treated Based Upon Religious Beliefs, 22 J. Contemp. Health L. & Pol’y 233, 236 (2006).

[2] Cardwell v. Bechtol, 724 S.W.2d 739, 741 (Tenn. 1987); Lawrence Schlam & Joseph P. Wood, Informed Consent to the Medical Treatment of Minors: Law & Practice, 10 Health Matrix 141, 141 (2000).

[3] Cardwell, 724 S.W.2d at 741.

[4] Will, supra note 1, at 236.

[5] In re Long Island Jewish Med. Ctr., 557 N.Y.S.2d 239, 243 (Sup. Ct. Queens County 1990). 

[6] N.Y. Pub. Health Law § 2803-c(3)(e) (McKinney 2010); Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261, 278 (1990); Fosmire v. Nicoleau, 551 N.Y.S.2d 876, 880 (1990).

[7] N.Y. Pub. Health Law § 2504(1) (McKinney 2010); N.Y. Dep’t of Health, Patients Care & Consent for Minors, http://www.health.state.ny.us/nysdoh/ems/policy/99-09.htm (last visited Jan. 20, 2010).

[8] Matter of Thomas B., 574 N.Y.S.2d 659, 660—61 (Cattaraugus County Fam. Ct. 1991) (holding that the court was justified in overruling a fifteen year old’s “vigorous objection” to surgery because it was in his best interests).

[9] Homer H. Clarke, Children and the Constitution, 1992 U. Ill. L. Rev. 1, 1 (1992).

[10] Planned Parenthood of Cent. Mo. v. Danforth, 428 U.S. 52, 74 (1976).

[11] Cardwell v. Bechtol, 724 S.W.2d 739, 749 (Tenn. 1987).

[12] Id.

[13] In re E.G., 549 N.E.2d 322, 327 (Ill. 1989); In re Swan, 569 A.2d 1202, 1204—06 (Me. 1990).

[14] Cardwell, 724 S.W.2d at 748.

[15] In re E.G., 549 N.E.2d at 327.

[16] Fosmire v. Nicoleau, 551 N.Y.S.2d 876, 881—83 (1990); Matter of Storar, 438 N.Y.S.2d 266, 273 (1981).

[17] Fosmire, 551 N.Y.S.2d at 880—81.

[18] Id.

[19] Id. at 883.

[20] Wisconsin v. Yoder, 406 U.S. 205, 245 (1972) (Douglas, J., dissenting).

[21] Fosmire, 551 N.Y.S.2d at 881.

[22] Matter of Storar, 438 N.Y.S.2d 266, 273 (1981).

[23] In re Long Island Jewish Med. Ctr., 557 N.Y.S.2d 239, 243 (Sup. Ct. Queens County 1990).

[24] N.Y. Pub. Health Law § 2504(4) (McKinney 2010).

[25] N.Y. Pub. Health Law § 2967(1)—(2) (McKinney 2010).

[26] In re Seiferth, 127 N.E.2d 820, 821, 823 (N.Y. 1955). 

[27] Id. at 822–23.

[28] In re E.G., 549 N.E.2d 322, 326 (Ill. 1989).

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2 Comments

Filed under Constitutional Law, Criminal Law, Health Law, Human Rights, Uncategorized

2 responses to “The Mature Minor Doctrine: Should a Mature Minor Have the Right to Refuse Life-Sustaining Treatment in New York?

  1. “Yoder, 406 U.S. 205, 245 (1972) (Douglas, J., dissenting).”
    Are you sure that this is so?

  2. Tyra Kvist

    Who makes the determination of maturity? The doctor? and is that enough? A psychiatrist? the Court?

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