In the United States, teenagers whose parents refused to vaccinate them are increasingly seeking vaccinations, although not all states have such an opportunity – usually, parental or guardian consent is required until the age of eighteen. The rights of juvenile patients is a complex topic, especially in the context of transgender transition or mutilation that intersex people undergo during infancy. We figure out at what age a child in Russia can independently decide on vaccination, whether a mother can attend her daughter’s visit to a gynecologist and how issues of the rights of underage patients are resolved in different countries.
What is the difficulty
Making decisions for a child is not as straightforward from an ethical point of view as it might seem. Most will agree that eliminating an immediate danger, stopping bleeding, and injecting medicine when indicated is a must, even if the child is against it (and he may be against it simply because the injections are painful and antiseptics sting the scratches). Refusal to treat a child in need of therapy can also be assessed quite unequivocally – here is another piece of news about a convicted mother whose child died of HIV infection. But between these extremes, there are many situations in which parents, without breaking the law, can harm the child. This includes refusal to vaccinate, insistence on unnecessary, in fact, operations in intersex children, circumcision , debates about the ethics of which do not subside , or cases when parents insist on continuing treatment that is no longer beneficial.
Canadian bioethics experts explain that decision conflicts can arise when the opinions and values of parents are contrary to the recommendations of health care providers. It is proposed to meet the parents halfway, but only when their decision does not harm the child. It is recommended to clarify the medical facts, prognosis, benefits and risks of treatment, and if disagreement continues , to offer a second opinion. If clinicians believe that parental decisions are clearly contrary to the best interests of the child or adolescent, it is recommended that an ethics committee or advisor be brought in to resolve the issue. The next level is child protection authorities and the legal system.
Back in 1982, one study found that medical decision making was not different between adolescents of fourteen and adults, and even nine-year-olds, although it was more difficult to convey information to them, were able to resolve issues related to their treatment. Participation in discussions and choice are important for a child – they help to feel like a person who is respected by others. In the Canadian publication mentioned above, it is recommended to give such an opportunity even to children of primary school age, within reasonable limits – for example, the child can choose which shoulder (right or left) he will be injected into, although he will not be able to refuse the injection.
A prerequisite for any medical intervention is obtaining prior voluntary informed consent. This consent is given either by the citizen himself or by his legal representative – the latter applies to children and to those who are recognized as incapacitated. The legal representatives of children are most often their parents. The age of consent is often equated to or near the age of majority – in different regions of Canada it is 16, 18 or 19, in Australia – 16, but sometimes a patient under this age can give consent (if, according to two doctors, the child is able to understand the nature , the consequences and risks of treatment, and the treatment itself is in the best interests of the patient).
In Israel, the age of consent is 18 years, with some important exceptions – for example, a patient of any age can give consent to an abortion and parental information or consent is not required. In the UK, people aged 16 and over can make their own medical decisions. In the countries of the European Union, the age of consent can range from 14 years (in Latvia) to 18 (in ten countries). In France, although up to 18 years of age the decision is made by the legal representatives of the child, they are obliged to take his opinion into account. In Austria, Belgium, the Czech Republic, Estonia, Germany, Luxembourg and Sweden, the age of consent for medical interventions is not fixed – and in each case the decision is made individually, depending on the child’s ability to participate in the process.
Some medical interventions are allowed without the consent of the patient (or his legal representative). In Russia, this is, for example, providing assistance in the presence of a threat to life: if emergency measures are needed to save a person’s life, and he cannot give consent (for example, he is unconscious), then doctors will save him. More informed consent is not required in relation to people with diseases that are a danger to others, persons with severe mental health problems, people who have committed crimes, as well as forensic medical or forensic psychiatric examination. According to the new bill , consent will not be required for the provision of palliative care.
Age of consent in Russia
The rights of patients in Russia are regulated by the Federal Law of November 21, 2011 No. 323-FZ ” On the Basics of Health Protection of Citizens in the Russian Federation ” and the Civil Code of the Russian Federation. In accordance with paragraph 2 of Article 54 (“The rights of minors in the field of health protection “) of the Federal Law, “minors over the age of fifteen years or minors with drug addiction over the age of sixteen have the right to informed voluntary consent to medical intervention or to refuse it “. Arina Pokrovskaya, lawyer, psychoanalyst, head of the Center for Psychology and Law ” Pokrov “, author of the book “Medical Law for Children and Parents”, explains that the concept of “older” includes the day of the onset of this age, that is, we are talking about people who have reached fifteen (or, respectively, sixteen) years. It turns out that a child can make an independent decision about, for example, vaccination, starting at the age of fifteen.
The right to medical secrecy in Russia also arises from the age of fifteen – however, the protection of personal data is broader than the issue of medical secrecy and is regulated by other special legislation. It happens that the parent insists on his presence during the child’s visit to the doctor – and the child has already reached the age of consent. This can be very uncomfortable for the patient or patient, especially when it comes to a delicate situation, such as a gynecological examination. According to Arina Pokrovskaya, in this case, the doctor must explain to the minor patient her right to confidentiality in an accessible form and invite her mother to be outside the door. But if the patient unequivocally agrees to the presence of her mother (or another relative) and this does not interfere with medical tasks, then the doctor has the right to conduct a visit with them.
As for the transgender transition and corrective surgeries, in Russia, in order to get a referral to a medical commission, which will give an opinion on such a possibility, you need to be seen by a psychiatrist for some time (from two months to two years). Formally, a patient from the age of fifteen has the right to turn to a psychiatrist to begin such observation.