This article examines the limitations of decision-making skills of children and adolescents in a medical context imposed by cognitive immaturity. The author considers the work of Piaget and other theorists who have addressed when children do and do not possess the requisite maturity to make their own decisions. Finally, the author proposes that providers individually assess the cognitive abilities of children in an attempt to ascertain when the child is able to make his or her own decision, regardless of chronological age.
Western medicine, which has traditionally encouraged autonomous decision-making by patients, faces a special challenge when the patient is a minor. The fields of law, medicine and cognitive development may provide guidance in determining when a child is an appropriate decision-maker and when parental involvement is mandated.
The common law has traditionally rccognized the Rule of Sevens, which finds that "(1) under seven years of age there is no capacity; (2) between 7 and 14 years of age there is a rebuttable presumption of no capacity, and (3) between 14 and 21 there is a rebuttable presumption of capacity" (Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987, cited in Rozovsky, 1990, p." 264). The law has therefore given its tacit approval of the concept of varying degrees of emotional and mental maturity to exercise judgment. Further, many states (such as Illinois) allow minors as young as 12 or 14 to receive treatment for outpatient mental health treatment, drug or alcohol abuse or for treatment of STDs without parental permission.
The American Academy of Pediatrics' (AAP) Committee on Bioethics developed a policy in 1995 in which they noted that "pediatricians should not necessarily treat children as rational, autonomous decision makers, but they should give serious consideration to each patient's developing capacities for participating in decision-making, including rationality and autonomy" (p. 315). The AAP Committee noted that medical staff should defer treatment to address patient concerns if the minor patient refuses to assent. Further, refusal to assent should "carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial nsk"(p. 316). Finally, they note "coercion in diagnosis or treatment is a last resort" (Shield & Baum, cited in AAP Committee Report, 1995, p. 315).
Research in Cogitative Development
A classic study (1983) conducted by Lois Weithorn found that subjects aged 9, 14, 18 and 21 presented with complex scenarios in which they had to make medical treatment decisions for others all used similar reasoning processes. In three of the four scenarios, the nine-year-olds did not differ significantly from adults in the options they chose. Interestingly, the single divergence from the other three groups occurred when the nine-year-olds indicated a greater preference for hospitalisation than outpatient treatment, evidence of "the notion that "more treatment" is necessarily "better treatment"" (Weithorn, 1983). Further, despite evidence that the nine-years exhibited less understanding about the information provided in the scenarios, they did display "an impressive level of understanding" and used important factors when weighing the different treatment options (Weithorn, 1983). While Wcithorn notes that children and young adolescents may be inappropriately motivated by the desire to please others and may be easily influenced by parents, providers and significant others, "minors may be more capable than we expect" (Weithom, 1983).
It is this knowledge that a minor patient may be capable of the requisite critical thinking that has justified granting them limited autonomy in some cases. Autonomy, which many ethicists consider to be the leading value in medical decision-making in western-influenced cultures, is routinely accorded to the vast majority of adult patients in this country. …