The 'mature minor' - What to consider when an adolescent requests a COVID-19 vaccination against their parents’ wishes

By Veronica Cerratti^,1,2 John Massie,^1,2,3 Jane Tuckerman,^1,2,3 Paula O’Brien,⁴ John Tobin⁴ and Margie Danchin^1,2,3,5 

Affiliations: 

1. The Royal Children’s Hospital, Melbourne 
2. Vaccine Uptake, Murdoch Children’s Research Institute  
3. Department of Paediatrics, The University of Melbourne 
4. Melbourne Law School, The University of Melbourne 
5. School of Population and Global Health, The University of Melbourne 

Source: APNA Primary Times Summer 2022-23 (Volume 22, Issue 2)

---

Children and young people represent over a quarter of active cases of COVID-19 in Australia, which have now surpassed 10 million.¹ While over 95% of the Australian population aged over 16 years has received at least two doses of a COVID-19 vaccine, coverage is much lower in younger age groups.² Perceived susceptibility to severe COVID-19 and conservative mandates about vaccination are likely contributing factors; however, some young people wish to be vaccinated for COVID-19, even when their parents do not agree. How vaccine providers respond poses a number of practical, ethical and legal considerations.

Since the early days of the pandemic, parents have taken some comfort from the fact that COVID-19 infection is much less likely to cause serious illness in children compared to adults. However, children and adolescents are still at risk of serious complications, especially those with certain underlying medical conditions. They might suffer from prolonged symptoms (‘long COVID’) or post-infectious multisystem inflammatory illness, and in some cases the illness can be fatal.³ The social, emotional, economic and educational consequences of the pandemic have been enormous for young people, with long periods of home learning, interruptions to sport and other co-curricular and social activities, and periods of isolation due to COVID-19 infection.⁴  

Internationally, young people have expressed a strong desire to be vaccinated,⁴ with vaccine hesitancy more frequently expressed by older adults and parents.⁵ Many young people are concerned about COVID-19 infection and either becoming unwell themselves or posing a risk of transmission to vulnerable family and friends.⁴ However, the strongest motivators for young people to be vaccinated have been around the broader benefits of vaccination and return to their way of life.  

 

The mature minor 

One way to consider this problem is through the legal framework of the ‘mature minor’. In Australia, a young person under the age of 18 may consent to medical treatment if they are assessed by the clinician to be a mature minor (also known as ‘Gillick competent’).⁶ When faced with a young person seeking the COVID-19 vaccine, a clinician is obliged to consider the young person’s ability and maturity to weigh up the risks and benefits specific to the vaccination. There is no lower limit to the age covered by the ‘mature minor’ doctrine.⁶  

 

Professional and ethical considerations 

Assuming that a young person has legal capacity to consent, administering the COVID-19 vaccination to a young person should align with a clinician’s professional obligation to act in the patient’s best interests. Vaccination for COVID‐19 has been proven safe and effective from the age of 6 months, and is recommended by the Australian Technical Advisory Group on Immunisation (ATAGI).⁷ While severe outcomes from COVID-19 infection in children are rare, the benefits of vaccination should be considered, especially for young people with underlying medical conditions that place them at increased risk^.3 While there has been some concern for pericarditis and myocarditis following COVID-19 vaccination, events are rare, occurring in less than one per 100,000 young people. Most of these cases have been mild, and patients have recovered quickly.8 

Consideration of the patient’s best interests must also take into account broader concepts than a simple risk–benefit assessment of a vaccination. Respecting the views of a young person, supporting them to engage with their own health care and the development of medical decision-making skills are also important considerations. This aligns with a human-rights-based approach that requires respect for several rights under the United Nations Convention on the Rights of the Child (UNCRC).⁹ These include the best interests principle (Article 3); a child’s right to survival and development (Article 6); a right to access the health care they need (Article 24); and the right of a child, ‘who is capable of forming her own views … to express those views freely in all matters affecting the child’ (Article 12). Article 5 of the UNCRC requires respect for the rights of the parents; however, this must be exercised in line with the evolving capacities of a child, and may change as the child grows.⁹ 

The young person’s right to privacy must be preserved in all cases. Medicare automatically restricts parental viewing of a child’s item numbers and vaccine administration from the age of 14, with younger people able to request specific details to be restricted.¹⁰ A clinician must then carefully manage the young person’s privacy with the ideal opening of communication between the young person and their family. Ideally, the young person should tell their parents in case they need to seek medical assistance in the days following vaccination. The young person may find it easier for the clinician to do this, but reassurance should be given that the doctor will not do this without their consent. There may be risk to the parent–child relationship due to vaccination without parental consent, and how this might play out should be considered. It is also possible that the clinician has a professional relationship with the young person’s parents and could feel conflicted about how this might affect the health-care relationships with the family.  
In conclusion, vaccinating a young person is a good medical, legal, ethical and human rights decision if the mature minor assessment is satisfied. In creating a space for conversation, the rights of the young person as well as their family can be supported. 

 

Find out more 

The Vax4Youth research team is currently investigating the issues surrounding COVID-19 vaccination for young people requesting vaccination without parental consent. The team is a collaboration between the Murdoch Children’s Research Institute, the Melbourne Law School, and the Children’s Bioethics Centre. The next phase of the project is a survey of primary health care practitioners in Victoria that aims to identify the scope and nature of encounters with young people aged 12–17 years wishing to be vaccinated for COVID-19 against the wishes of the parent or guardian or where it is contested. The Vax4Youth survey will be advertising via VicREN and public health networks shortly. Questions and comments may be directed to vax4youth@mcri.com.au.  

 

How to respond when a young person (aged 12–17 years) requests a COVID‐19 vaccine 

Assess the young person’s history, motivations, capacity	Age, education level, medical history
Ask about the parents’ or carers’ views	Clarify guardianship details. Ask about both parents’ or carers’ views.
Discuss the benefits and risks of COVID‐19 vaccination	General screening questions, common and expected side-effects, rare but serious side-effects
Recommend the child involves their parents	Be prepared to support the young person. Have a plan for follow up in case of side-effects.
Privacy	If the child is aged 12–13 years, ask if they wish to have their Medicare record made private.
Document consent for vaccination	Upload the vaccine record to the Australian Immunisation Register.

Adapted (with authors’ permission) from: J Massie, GA Paxton, N Crawford and MH Danchin, ‘Vaccination of young people from 12 years of age for COVID-19 against parents’ wishes’, Med J Aust, 2022, 216(9):455–457. 

 

References 

1. Australian Government Department of Health and Aged Care, ‘Coronavirus (COVID-19) case numbers and statistics’, 7 October 2022, accessed 9 October 2022. www.health.gov.au  

2. Australian Government Department of Health and Aged Care, ‘Vaccination numbers and statistics’, 7 October 2022, accessed 9 October 2022. www.health.gov.au 

3. J Massie, GA Paxton, N Crawford and MH Danchin, ‘Vaccination of young people from 12 years of age for COVID-19 against parents’ wishes’, Med J Aust, 2022, 216(9):455–457. 

4. M Fazel, S Puntis, SR White et al., ‘Willingness of children and adolescents to have a COVID-19 vaccination: Results of a large whole schools survey in England’, EClinicalMedicine, 2021, 40:101144. 

5. LG Borga, AE Clark, C D’Ambrosio et al., ‘Characteristics associated with COVID-19 vaccine hesitancy’, Sci Rep, 2022, 12:12435. 

6. Gillick v West Norfolk AHA [1986] AC 112, 188–189.  

7. Australian Government Department of Health and Aged Care, ‘COVID‐19 vaccination: ATAGI clinical guidance on COVID‐19 vaccine in Australia in 2021’, 2021, accessed 30 September 2022. www.health.gov.au 

8. Melbourne Vaccine Education Centre, ‘Myocarditis and pericarditis following COVID-19 vaccines’, 27 October 2022, accessed 1 November 2022. https://mvec.mcri.edu.au 

9. J Tobin and S Varadan, ‘Article 5: The right to parental direction and guidance consistent with a child’s evolving capacities’, in Tobin J (ed), The UN Convention on the Rights of the Child: A Commentary, Oxford University Press, Oxford, 2019. 

10. Services Australia, ‘What happens when your child turns 14’, 28 June 2022, accessed 9 October 2022. www.servicesaustralia.gov.au