Adolescent decision-making in Canadian medical contexts: Integrating neuroscience and consent frameworks

Abstract

The primary objective of this commentary is to integrate current neuroscientific research on brain development during adolescence, with existing consent frameworks that do not designate a minimum age for eligibility to consent to, or refuse medical treatment. To reach this objective, the three consent frameworks used in health care settings are outlined: age-based framework; mature minor framework and capacity-based framework. This commentary draws on the Canadian health care system specifically to consider consent frameworks that grant young people with decision-making capacity. Next, a brief review of adolescent brain development findings is presented, particularly pertaining to the decision-making capacity of young people within medical contexts. Ultimately, the question of whether the stage of a young person’s brain development impedes their capacity to consent to, or refuse medical treatment is addressed. This commentary provides reassurance as to the compatibility between capacity-based and mature minor frameworks to consent to treatment with current neuroscientific understanding of adolescent brain development.

Current understanding of adolescent neuroscience holds that brain development continues into an individual’s mid to late-20s (1). This finding may raise the question of young patients’ ability to make capable health care decisions. The importance of examining how adolescent brain development is integrated into adolescent decision making is a timely research endeavour, most recently highlighted by Grootens-Wiegers et al. (2) in a review that considers specific brain regions implicated in each neurological skill required in child and adolescent decision-making capacity. The current commentary similarly considers the integration of neurologic understanding of brain development into decision-making capacity in adolescents, in a Canadian context.

CONSENT FRAMEWORKS

A core value of bioethics is respect for an individual’s autonomy, embodied as the self-determined capacity to consent to treatment with full information, understanding, and voluntariness. In paediatric health care, this value is upheld by facilitation and fostering of the emerging autonomy of young people. While the concept of capacity to consent is universally established across health care institutions, the legal bounds designating who is capable of providing consent to treatment vary between provinces and states. Three common frameworks for determining eligibility to consent are discussed in this paper: age-based framework; mature minor framework and capacity-based frameworks.

An age-based framework of consent to medical treatment simply abides by a strict age of majority, where any adolescents of or older than said age are deemed capable of consenting to treatment. The only Canadian example of an age-based framework is found in Quebec, where, an age of majority of 14 and older to consent to medical treatment is adhered to (CQLR c CCQ-1991, c. 64, a. 14.) (3).

A mature minor framework holds that an individual under the age of majority in their given province may qualify for mature minor status, requesting to be recognized as capable of consenting to a given medical treatment based on factors such as significant experience within the health care system. For example, in Manitoba and New Brunswick, an adolescent under the age of 16 (the age of majority) is presumed not to have capacity, but the presumption is rebuttable with evidence to the contrary. In provinces that do not have consent and capacity legislation, common law governs (Nova Scotia, Newfoundland and Labrador, the Northwest Territories and Nunavut). The Supreme Court of Canada endorses the mature minor doctrine in these provinces.

Lastly, a capacity-based framework designates no specific age of consent and instead relies on capacity as the sole measure of eligibility (in Ontario, Alberta, British Columbia, PEI, the Yukon and Saskatchewan). Under the Health Care Consent Act (HCCA) in Ontario, for example, capacity to consent is legally defined as a threshold that requires two components: ‘understanding’—of relevant information, and ‘appreciation’—of possible consequences to accepting or rejecting the treatment option (1996, c. 2, Sched. A, s. 4 (1,4)).

Age-based frameworks measure capacity to consent based on age alone, while the latter two frameworks interpret capacity on a case-by-case basis, considering factors beyond solely age. Canadian law largely recognizes that decision-making capacity is not tied solely to age, rather a broader understanding of capacity.

Capacity-based and mature-minor frameworks for consent therefore are the prime focus of this commentary as they place the most confidence and subsequent responsibility in adolescents’ decisional capacity and are found in Canadian health care contexts.

ADOLESCENT BRAIN DEVELOPMENT

In many respects, adolescents are competent to engage fully in making decisions and consenting to treatments related to their health care. Grootens-Wiegers et al. recently outlined evidence of the prerequisite skills of communication, understanding, and reasoning to support sufficient competency for medical decision-making in the early teen years (2). However, the brain continues to develop through adolescent years and this evidence has been used to question full adolescent capacity to engage in informed consent.

It is well recognized that the brain continues to develop throughout adolescence and into young adulthood. Historical findings emphasize structural brain changes with evidence from MRI, identifying gray and white matter changes throughout different regions of the brain (5,6). This process reflects a fine-tuning and strengthening of connections and communication between cortical and subcortical regions. Functional imaging has helped further examine and explain how adolescents differ from children and adults in terms of risk-taking behaviour (7,8). From this work, several models have been proposed. One of the most cited, Steinberg’s dual systems (2009), has achieved much attention for its application to age-based social and legal policy.

The dual systems model proposes that risk taking behaviour and poor decision-making peaks in adolescence because of increased activity or sensitivity within the socioemotional system (i.e., subcortical structures, including the ventral striatum of the basal ganglia). These structures typically mature during late childhood and early adolescence, explaining amplified reward-seeking behaviours (9). In contrast, areas of the prefrontal cortex responsible for cognitive control (i.e., self- regulation and impulse control) matures more gradually over adolescence and into early adulthood. This developmental difference explains how in certain circumstances some adolescents have difficulty restraining impulsive and, or reward seeking behaviours, which interfere with good decision- making. Recently, Casey argued for the benefits of understanding adolescent brain development from an ‘imbalance model’, an integrated circuit-based perspective. Specifically, this model emphasizes how changes in self-control coincide with a series of developmental cascades in the regional fine-tuning of reciprocal connections within complex cortical prefrontal and subcortical limbic circuits (10). Her model emphasizes the dynamic neurochemical, connectivity and functional interactions across development that are essential for self-control.

In both adolescent risk-taking and decision-making models, several moderators of behaviour have been identified. First, the presence of peers elevates adolescent susceptibility to poor decision-making, e.g., impulsive driving decisions, alcohol consumption (11,12). Additionally, emotional states such as perception of threat or perceived immediate reward, were associated with more impulsive responses by adolescents compared to young adults and children (13,14). Conversely, in neutral or non-peer-mediated circumstances, adolescents do show good decision-making and minimal impulsivity (11,15).

These models have yet to consider how this circuitry influences adolescent medical decision-making. The decisions to decline a surgical intervention or treatment, compared to the decisions to engage in risky behaviours tested in imaging studies listed above, are significantly different. Often peers are not part of medical conversations, and actually may be a motivator to improve one’s health status to be more socially active.

The emotional impact on adolescent decision-making, however, is likely highly relevant. Careful consideration and support for these issues are particularly helpful to optimize adolescents’ capacity and decision-making success in these situations. Other important factors to consider are the adolescents’ medical knowledge and chronicity of their health care condition, which may actually enhance decision-making capacity.

DISCUSSION

Neuroscience models examining the continued development of the adolescent brain tend to focus on the vulnerabilities associated with adolescence and raise concerns of adolescents engaging in ‘riskier’ decisions, strongly mediated by the presence of a peer-laden social or distinctly emotional context (16).

Yet, under conditions that mitigate socioemotional arousal and allow for calculated, deliberative decision-making, and adolescents demonstrate near adult-like capacity (11,15). In most circumstances, adolescents are found to be competent to engage fully in medical decision-making.

The most recent American Academy of Pediatrics (AAP) Policy Statement on Informed Consent in Decision-Making in Pediatric Practice cited a literature review by Lipstein et al. (17) that listed provider relationships, previous knowledge, emotions, change in a child’s health status, and faith as influencing factors. The AAP statement further highlights cultural, social, and religious factors as mediating factors in medical decision-making. Adolescent brain development is an added factor influencing decision-making. The importance of considering the entirety of a young person rather than narrowing in on age in determining capacity to consent to medical treatment is reinforced by the 2016 AAP statement and further supported in this commentary and by Grootens-Wiegers et al. (2).

Unanswered questions remain in the form of further research opportunities for the application of the neuroscience of adolescent brain development in health care decision-making. A few examples include, the potentially emotionally-laden contexts of medical settings and their consequent effects on impulsivity; the effects of chronic illness and/or pain on decision-making capacity; and understanding the relationship between moral development and cognitive development in adolescents. These opportunities for further research may serve to be clinically valuable in optimizing paediatric care provision by facilitating adolescent decision-making capacity.

CONCLUSION

Issues pertaining to adolescents’ capacity to consent to medical treatment are ongoing given constantly evolving medical technologies and novel treatments opportunities, particularly in paediatric settings. While increased propensity towards risk-taking behaviour is observed in adolescents in socially-mediated contexts, it is well accepted that adolescents can still meet the threshold of providing capable consent to decisions related to their health care as they exhibit low impulsivity and sound decision-making under neutral contexts (2,10,15) Compatibility can therefore be assured between current Capacity-based or Mature-Minor consent frameworks in Canadian contexts with current neuroscientific understanding of adolescent brain development.