Adolescents are more likely to make rash and

impulsive decisions Larcher 12

Adolescence is a time of transition between
dependence and vulnerability of childhood and the autonomy (the

the

capacity and ability to make free informed choices) of adulthood. Young children lack this capacity; others have the
moral and legal authority to act for them, provided they act in childs best interests.

adolescents right to consent and

confidentiality depends on their capacity to exercise it .
Legally, it seems that

Ethically, professionals have a duty to respect and enhance adolescents evolving capacity to make health care
choices and respect their confidentiality, provided that doing so does not produce harm to adolescents or to others.

Healthcare professionals have a fundamental

duty to act in the best interests of their patients. This entails two sometimes conflicting obligations, namely
to produce as much overall benefit as possible and to
respect as much autonomy as the patient is capable of exerting. Great emphasis is
placed on the duty to respect patients autonomy in adult healthcare, no matter what their choice is, but what
duties should be owed to adolescents? To what extent should their evolving capacity to consent or refuse treatment
or their right to confidentiality be respected? The latter is regarded as especially important by young people
because it underpins future relationships with professionals and is founded on mutual trust. Ethically, professionals
have a duty to respect and enhance adolescents evolving capacity to make health care choices and respect their

provided that doing so does not

produce harm to adolescents or to others.
The rate at which adolescents capacity for medical
decision-making evolves depends on the complexity of
their medical condition, their understanding or experience of it, and other
contextual factors such as culture, family and belief systems. Evidence suggests that 14-15 year
olds have similar capacities to adults (Weithorn and
confidentiality,

Campbell,1982).
In English law, the capacity of under 16 year olds to consent is determined by whether they have achieved
sufficient understanding and intelligence to enable them to understand fully the nature and purpose of what is

but this does not mean, as might logically be supposed, that

they have a right to veto treatment that is in
their best interests. This apparent inconsistency can be justified by the obligation to
proposed.

protect vulnerable individuals from harmful or inappropriate choices: for instance, refusing a lifesaving medical
intervention such as transplantation because they are frightened to undergo it or do not understand the
consequences for their family if they do not.

Adolescents may not always act in a way that is consistent with their
presumed capacity for rational thought and for them analytic
processes may not be the primary means of decision making. They may show a

significant emotional component to decision making

because of their concerns with external
influences like others perceptions and peer group pressures. Purely cognitive
assessment of capacity may not take sufficient
account of emotional and psychological
components of decision making and their impact in real life
situations. This dualism between the rational and the emotional appears important in considering adolescent
approaches to core moral judgments of which treatment decisions may be an example.

brain maturation provides

a possible explanation of the adolescents emotional
responses to decision making. The Prefrontal Cortex
(PFC) is not fully developed until the 20s. It is considered
the seat of the rational brain, since its functions include
high level reasoning, decision making,
impulse control, assessment of
consequences, forward planning behavior
modification and priority setting. In contrast, the
amygdale, concerned with the formation and storage of memories
associated with emotional events, is relatively more
developed in adolescents. This relative lack of
development of the PFC in adolescents might
explains some of their recognised behaviours e.g. impulsivity,
inflexibility, emotional volatility, risk taking
short termism. These behaviour traits, to the extent to which they pose risks
of harm to the adolescent or others, may cause
professionals to question how much they should respect an
adolescents right to confidentiality and how much they
Our increasing understanding of the process of

should intervene to prevent harmful outcomes.

An adolescents objections to disclosure of information should largely be honoured, but it is reasonable to try to
persuade them to permit disclosure if it is felt in their best interests to do so. Where refusal is persistent, the need
for disclosure must be justified by the belief of serious risk of harm to the adolescent or others or by legal
requirement. For example, the need for disclosure may be justified in a case where an adolescent would visit the
emergency room with an inflicted wound but would refuse to allow details of it to be disclosed to investigating
authorities. Even so, transparency requires that the adolescent is told that information will be disclosed and the
reasons for it.
Although

adolescents can, they are arguably less likely to make

rational decisions in conditions of high

emotion or intense pressure and. They are more
likely to act impulsively or without full consideration of the consequences. This
may be the case when adolescents refuse treatment that is intended to prevent death or serious harm. Assessment
of their capacity to refuse needs to take account of their experience of illness or treatment, any settled values they
have and the practicalities of delivery of the treatment itself (it would, for example, be practically difficult to
administer transfusion or intravenous drugs to a well grown sixteen year old without his co-operation).
Management of healthcare problems in adolescents involves a delicate balance between protecting them from
harms that may be an intrinsic consequence of their developmental state, whilst respecting them as persons in
whom capacity is developing and should be fostered. Practically, this requires involving adolescents in discussions
and decisions, and in recognising and acknowledging their developing capacity. However it is also important to be
clear that some decisions are flawed and should be questioned and that some limits to recognition of full autonomy
may be necessary and ethically justifiable.