Sunday, September 13, 2015

LD Sep/Oct 2015 - Adolescent Right to Make Medical Choices - Negative Position


Resolved: Adolescents ought to have the right to make autonomous medical choices.


For previous articles in this series, click here and here.


The Neg Position

Now that you have read the introduction and had time, perhaps, to absorb the Affirmative point of view, let's flip things around. There are many good arguments on the Neg side and I will explore a few of them.  First of all, the capability of all adolescents to make good decisions is not exactly a consistent tenet in U.S. law. On the one hand, the law suggests adolescents should have autonomy in making some kinds of medical decisions such as abortion, pregnancy prevention or treatment for substance abuse and on the other hand, the law holds that adolescents' decision making capability is deficient enough to justify different and more lenient treatment in the criminal justice system. It seems there are times when perhaps adolescents can make legally reasonable decisions and other times they can not. Yet the Affirmative burden is to defend the idea adolescents ought to have decision-making autonomy.  There are no qualifications to the position, so we consider all adolescents ought to have the right. Perhaps we could capitulate and agree that "all" has the same limits imposed on adults of 18 years or older. It seems reasonable we can exclude individuals whose ability to make decisions is limited due to debilitating illness or injury, or who have demonstrated a lack of ability to make decisions which are self-beneficial to the satisfaction of a court.

One important position I would like to put forth in this analysis is the argument that legal decisions supporting decision making by minors is not based upon any particular widespread notion that adolescent autonomy should be absolute or even a primary consideration by states in allowing adolescents a voice in personal medical decisions. Let's see how this develops.


Unreasonable Reasoning

Perhaps we can agree that adolescents ought to be allowed to make autonomous medical decisions as long as those decisions appear to be well-reasoned and conform to what the majority of rational adults would think. But, what if the adolescent decision was contrary to what would be considered a rational consideration?  One is faced with two possibilities; either the adolescent is incapable of making a rational decision for any number of reasons unique to the individual's status of being "underage" or the adolescents' wishes should be honored despite the interests of others such as parents, or greater society. The line between these points of view represents a razor edge upon which the state must tread in executing its responsibility to serve the best interests of citizens and to preserve life. This duty is linked very firmly in the social contract.

Leonard (2015)
[Dr. Douglas S.] Diekema says adolescents' brains are not adequately developed to make these kinds of decisions, that they are heavily influenced by social and emotional reactions, including the wishes of friends and family. "It's the role of the state to protect children," he says. "Just because we let them make decisions at 18 is not a sufficient enough reason to let them make them at 17. ... I'm not saying they shouldn't be involved or shouldn't have their wishes respected, but at a certain point you have to set a limit." [ellipses in original source]

The above quotation refers to the case of a Connecticut teenager who objected to a potentially life-saving treatment for a form of leukemia.  Her decision was shocking and some may think irrational since the treatment is considered 85% effective at curing the patient. The State Supreme Court ruled the girl must receive treatment in compliance with state laws; laws aimed originally at protecting public health and the best interests of citizens, including children. A similar case, involving a younger adolescent occurred in Minnesota where a teen refused 90% successful, life-saving chemotherapy citing strong beliefs in Native American "medicine man" treatments and religious ideology.

There are many examples of the state intervening in medical decision making which has direct application to the Negative position in this resolution. In fact, there are times when even the decisions of adults violate public interests and so it can be argued personal autonomy has limits enforced by just governments.


Adolescent Health and the Public Interest

The health choices of a teenager with a potentially life-threatening disease may seem to have minimal impact on the best interests of society at large and the responsibility of states to protect those interests.  After all, there is little doubt, many adults make the decision to refuse life-saving treatment and we usually never hear about it much less consider the impact of the decision on societal well-being.  However, personal health decisions and public health concerns very often overlap. It can be argued, for example, that risky behaviors such as engaging in substance abuse, violence or unsafe sex are in fact choices with wide-ranging public health implications.  Therefore, if teens are inclined to make choices without regard to public health risks a guarded consideration of their choices in routine medical decisions is warranted.

WHO (2014)
The life-course provides an important perspective for public health action. Events in one phase of life both affect and are affected by events in other phases of life. Thus, what happens during the early years of life affects adolescents’ health and development, and health and development during adolescence in turn affect health during the adult years and, ultimately, the health and development of the next generation. Effective interventions during adolescence protect public health investments in child survival and early child development. At the same time, adolescence offers an opportunity to rectify problems that have arisen during the first decade. For example, interventions during adolescence may decrease the adverse long-term impacts of violence and abuse in childhood or of under-nutrition and prevent them from undermining future health. [3]

The law makes exceptions for adolescent medical decisions, precisely because the state rightly recognizes the oft-time impulsive, thrill-seeking, risk-taking decisions taken by teens can have far reaching public health implications.

Campbell (2013)
Adolescent motherhood has a multitude of consequences, both negative and positive, not only for the adolescent mother but also for her children. Adolescent mothers are less likely to finish high school and are often unable to maintain consistent employment, which leads to welfare dependence (Singh, Darroch, & Frost, 2001). Furthermore, many adolescent mothers continue through life as single parents, which also cause higher dependence on public assistance, higher stress, and more difficulty with childrearing (Black et al., 2006). Infants of adolescent mothers are more likely to be low birth weight, have childhood health problems, experience child abuse and neglect, be placed in foster care, and experience school problems such as truancy, grade repetition and early sexual initiation (Klerman, Baker, & Howard, 2003; Levine, Emery, & Pollack, 2007). Moreover, with each additional child born to an adolescent mother, the previous children are at higher risk for neglect, trauma, and delinquent behavior. These children often continue the cycle of adolescent pregnancy (Black et al.; Klerman et al.).

There is an overarching utilitarian consideration permitting minors to privately seek and consent to medical treatment or procedures which is not motivated by pressure to preserve the autonomy of minors. States are motivated by their fiduciary responsibility to preserve the quality of life of citizens. The risky decisions taken by minors with respect to substance abuse and unprotected sex contributes to the proliferation of HIV, HPV, and other communicable diseases.

Gittler, et al (1990)
The fact that these statutes impose either no age limit or a very low age limit for minors to consent to or to receive services for these diseases without parental consent appears to stem from a legislative recognition that society has a critical interest in facilitating and encouraging access to health services to reduce the spread of disease among its citizens.[128]

While governments will make exceptions and indeed, the Supreme Court has upheld a certain allowance for minors to make decisions which can ultimately minimize harms to society, recognition of parental rights predates the emergence of increasing risks of unwanted teen pregnancy or diseases spread by risky behavior. The recognition of parental authority also serves an overarching public interest.

Gittler, et al (1990)
Another rationale for the parental consent requirement—apart from the need to protect minors from their own improvident decisionmaking--is a belief that the parental consent requirement promotes family autonomy and privacy and promotes parental authority and control of minor children. Family autonomy and parental authority, in turn, are often viewed as fostering the stability and cohesiveness of the family as an institution and of individual family units. The U.S. Supreme Court has commented in a series of decisions on the importance of family autonomy and parental authority, and the Court has extended Federal constitutional protection, albeit not absolute protection, to family autonomy and parental authority . The parental consent requirement also seems, at least somewhat, to be designed to protect parents from financial liability arising from the provision of health services, without their consent, to their children and to ensure providers of the availability of a payment source for the services they provide to minors. [125]


Changing Minds

In the Affirmative position we looked at the physical development of the adolescent mind and in particular the prefrontal cortex region which is responsible for inhibiting impulsive behavior.

Anderson (2011)
The frontal lobe, the judgment center or CEO of the brain, allows the individual to contemplate and plan actions, to evaluate consequences of behaviors, to assess risk, and to think strategically. It is also the “inhibition center” of the brain, discouraging the individual from acting impulsively. The frontal lobe ultimately develops connections to many other areas of the brain, so that experiences and emotions are processed through the judgment center. The frontal lobe does not fully mature until approximately 23 – 25 years of age. The immaturity of the adolescent’s judgment center explains much of the inability of adolescents to properly interpret experiences in the environment and thus make appropriate and healthy decisions. Many other areas of the brain likewise are not completely myelinated until the early 20s. The amygdala, which is the emotion center of the brain, is immature in adolescents and not fully connected to the frontal lobe. Adolescents, then, may have a more difficult time interpreting their emotions, as well as the emotions of others.

Despite the fact the decision-centers of the brain do not fully develop until the mid-twenties some researchers and advocates claim adolescents can make good medical decisions under the right conditions, free from peer-pressure or stress. Yet in reality such decisions must be made under extreme duress and pressure, the kinds of decision-making environment which stimulates impulsive thinking. Studies show the lack of risk-aversion and desire for reward in adolescents results in decisions which favor high-risk gambles with greater reward rather than low-risk gambles with small rewards.

Burnett, et al (2010)
The extent of risk maximisation differed by age. There was an inverted U-shaped relationship between age and the influence of risk on decision-making. Logit regression showed that the impact of the difference in risk between alternatives increased with age at the younger end of the age range. Toward the middle of the age range, the increase in impact of the difference in risk started to decrease with age. By adulthood, the effect was reversed. That is, adolescents showed the strongest tendency to select high-risk gambles. In addition, there was a significant effect of age on the proportion of trials for which participants selected the high risk alternative. Young adolescents (aged 12–15) made a significantly greater proportion of risky choices than did adults, and the age at which risky choices peaked was 14.38 years. [194]


Another Interpretation of Rights

Within the U.S. and international community there is a defacto recognition that all human beings deserve respect and dignity, regardless of their age. However, the decision to permit autonomous decision making for minors is not at all cut and dry. Consider the following explanatory report arising from the Convention on Human Rights and Biomedicine.

COE (2001)
As indicated before, the second and third paragraphs prescribe that when a minor (paragraph 2) or an adult (paragraph 3) is not capable of consenting to an intervention, the intervention may be carried out only with the consent of parents who have custody of the minor, his or her legal representative or any person or body provided for by law. However, as far as possible, with a view to the preservation of the autonomy of persons with regard to interventions affecting their health, the second part of paragraph 2 states that the opinion of minors should be regarded as an increasingly determining factor in proportion to their age and capacity for discernment. This means that in certain situations which take account of the nature and seriousness of the intervention as well as the minor's age and ability to understand, the minor's opinion should increasingly carry more weight in the final decision. This could even lead to the conclusion that the consent of a minor should be necessary, or at least sufficient for some interventions. Note that the provision of the second sub-paragraph of paragraph 2 is consistent with Article 12 of the United Nations Convention on the Rights of the Child, which stipulates that "States Parties shall assure the child, who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child".

Nowhere in the preceding statement is the claim made that adolescents ought to have autonomous decision making rights.  It reasonably considers the best way to respect the autonomy and thus dignity of minors is allow them who are deemed capable of forming views to express them. The convention statements imply there is a great deal of variability in the capability of adolescents which must be evaluated on a case-by-case basis and by expressing their views, minors serve ever-increasing roles in a collective decision making process as their capability matures. So what about all those studies which claim adolescents are just as capable as adults to make autonomous medical decisions. Are they sufficient grounds for making policy decisions?

Gittler, et al (1990)
Are the empirical studies reviewed in this chapter sufficient to establish that adolescents as a group, ages 14 or 15 and above, are competent to consent to their own health care? Probably not. Beyond being rather few in number, the studies reviewed leave gaps in the knowledge ideally needed for the formulation of public policy pertaining to adolescents’ involvement in health care decisionmaking. One limitation of the available studies is that most of them did not examine minors’ decisionmaking performance in situations sufficiently real and stressful to see what effects such situations may have on their decisionmaking performance (although the few that did examine this found the same pattern of results as the other studies). Another limitation of the available studies is that they generally compared minors’ decisionmaking with the decisionmaking of very young adults rather than with that of adults of various ages. Still another limitation of available studies is that they leave open several important questions about the effects exerted on minors’ decisionmaking by factors such as socioeconomic status, ethnicity, social influence, skill training, and experience, and how these might interact with the age-competence relationship found in the generally white middle-class groups studied. It is difficult to know how well one may generalize from the groups studied to the groups not studied. [148-149]

The Gittler, et al paper continues:

Gittler, et al (1990)
Some of the empirical studies reviewed for this chapter note the great variation of performance within age groups, but they do not go beyond that. Because of individual variation in decisionmaking capacity among adolescents, some adolescents ages 14 and older do not, in fact, have the requisite capacity to make health care decisions. Even if the average minor of any given age group can make health care decisions as well as the average adult, if the variability is much greater among the minors than it is among adults, then a large absolute number of minors might fall below whatever the standard of competence is.[149]

It is the variability of this age-range which forces us to Negate the resolution. The State has a responsibility to protect its citizens and all the more protect minors who are incapable of protecting themselves. Sufficient evidence exists that while some minors may be capable of making self-benefiting decisions, there are many who do not  Dr. Steinberg claims the age of maturity is variable and usually falls within the range of 15 to 22 years. So given the variability how can lawmakers establish an appropriate age when minors as a class can make autonomous medical decisions?

Steinberg (2012)
The first option is to pick the mid-point of this range. Yes, this would result in classifying some immature individuals as adults and some mature ones as children. But this would be true no matter what chronological age is picked, and assuming that the age of neurobiological maturity is normally distributed, fewer errors would be made by picking an age near the middle of the range than at either of the extremes. Doing so would place the dividing line somewhere around 18, which, it turns out, is the presumptive age of majority pretty much everywhere around the world. In the vast majority of countries, 18 is the age at which individuals are permitted to vote, drink, drive, and enjoy other adult rights. And just think—the international community arrived at this without the benefit of brain scans.


The Value Decision

To conclude this Neg position, I will spend some time discussing the all-important value framework inherent in this analysis. The social contract theory is based upon the philosophy that free and autonomous individuals, defer some of there freedoms to the state in order to gain the protection of the state.

Friend (undated)
According to [Thomas] Hobbes, the justification for political obligation is this: given that men are naturally self-interested, yet they are rational, they will choose to submit to the authority of a Sovereign in order to be able to live in a civil society, which is conducive to their own interests...According to Locke, the State of Nature is not a condition of individuals, as it is for Hobbes. Rather, it is populated by mothers and fathers with their children, or families - what he calls "conjugal society". These societies are based on the voluntary agreements to care for children together, and they are moral but not political. Political society comes into being when individual men, representing their families, come together in the State of Nature and agree to each give up the executive power to punish those who transgress the Law of Nature, and hand over that power to the public power of a government. Having done this, they then become subject to the will of the majority. 

Based upon this theory, the government has a responsibility to protect the rights of citizens and those extend to the youngest members. However, a just government cannot play favorites in executing its fiduciary requirement to guard the best interests of the citizens.  Its decisions are typically utilitarian in nature, designed to maximize the greatest good for the greatest number balanced against the obligation to protect those who are unable to protect themselves. This idea leads naturally to the values of societal welfare/well being and governmental legitimacy through upholding the social contract or upholding the duties of governments.  While the rights and autonomy of all individuals should be protected and respected, there are limits to freedom in civil society.  Due to the variability and uncertainty of the capabilities of adolescents to make rational decisions under pressures and stresses accompanying critical medical decisions supporting the resolution exposes potential societal harms as well as risks to minors. For this reason I must negate.



Sources:

Anderson, J (2011), he Teenage Brain: Under Construction, American College of Pediatricians, May 2011. Accessed Aug 22, 2015:
https://www.acpeds.org/the-college-speaks/position-statements/parenting-issues/the-teenage-brain-under-construction

Burnett S; Bault, N; Coricelli, G; Blakemore, SJ, Adolescents’ heightened risk-seeking in a probabilistic gambling task, Elsevier Inc. doi:10.1016/j.cogdev.2009.11.003, 2010. Access on Aug 22, 2015:
http://ac.els-cdn.com/S0885201410000201/1-s2.0-S0885201410000201-main.pdf?_tid=74090236-5978-11e5-82c3-00000aab0f01&acdnat=1442081138_d5962a4827b050a326722b2a0ef4f6de

Campbell, D. (2013), Adolescent Mothers' Decisions Impacting Additional Pregnancies, Submitted to the graduate faculty of The University of Alabama at Birmingham, in partial fulfillment of the requirements for the degree of Doctor of Philosophy BIRMINGHAM, ALABAMA ,2013. Accessed Aug 22, 2015:
http://www.mhsl.uab.edu/dt/2014r/Campbell_uab_0005D_11115.pdf

COE (2001), Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine, Council of Europe, 2001
http://conventions.coe.int/Treaty/EN/Reports/Html/164.htm

Friend, C. Social Contract Theory, Internet Encyclopedia of Philosophy and its Authors, ISSN 2161-0002. accessed Aug 23, 2015:
http://www.iep.utm.edu/soc-cont/

Gittler, J, Quigley-Rick, M, Saks, MJ, Consent and Confidentiality in Adolescent Health Care Decisionmaking, Adolescent Health—Volume III: Crosscutting Issues in the Delivery of Health and Related Services, (This chapter is based on a February 1990 background PaPer entitled “Adolescent Health Care Decisionmaking: The Law and Public Policy,” prepmed for OTA’s Adolescent Heath Project under contract to the Carnegie Council on Adolescent Development by J. Gittler, M. Quigley-Rick, and M.J. Saks. That background paper has been published separately in its entirety, including extensive legal citations, and is available from the Carnegie CounciI on Adolescent Development, WashingIon, DC, or from OTA)
https://www.princeton.edu/~ota/disk1/1991/9104/910406.PDF

Leonard, K, (2015), Case Sparks Debate About Teen Decision Making in Health, U.S. News and World Report, News, accessed Aug 22, 2015:
http://www.usnews.com/news/articles/2015/01/22/case-sparks-debate-about-teen-decision-making-in-health

Steinberg, L (2012), Should the Science of Adolescent Brain Development Inform Public Policy?, Issues in Science and Technology, Volume XXVIII Issue 3, Spring 2012. Accessed Aug 22, 2015:
http://issues.org/28-3/steinberg/

WHO (2014), Health for the World’s Adolescents A second chance in the second decade, World Health Organization, WHO/FWC/MCA/14.05, 2014. Accessed Aug 22, 2015:
http://apps.who.int/adolescent/second-decade/files/1612_MNCAH_HWA_Executive_Summary.pdf

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