Special populations (minors, mentally ill)

Informed Consent - The Consent Cornerstone

• Minors (typically <18):

  • Require parental/guardian consent.
  • Should provide assent (agreement) if developmentally able.
  • Exceptions for consent: Emancipated minors, emergency situations, or specific services (e.g., contraception, STI treatment, substance abuse).

• Mentally Ill/Incapacitated:

  • Decision-making capacity is a clinical determination; competence is a legal one.
  • A psychiatric diagnosis ≠ incapacity.
  • If lacking capacity, decisions fall to a surrogate (healthcare proxy, family) or advance directive.

⭐ In emergencies, life-saving treatment can proceed without consent if waiting for a surrogate would result in significant harm.

Minors in Consent - Not-So-Little Decisions

• General rule: Individuals < 18 years old require parental/guardian consent for medical treatment.
• Assent: Always seek assent (agreement) from the child (usually age 7+), even with parental consent. It respects the child's emerging autonomy.

Exceptions allowing minor's sole consent:

• Emergency Care: Implied consent applies; treat immediately if life/limb is at risk.
• Emancipated Minor: Legally recognized as an adult.
  • Married, in the military, financially independent, or a parent.
• Specific Health Services (State-dependent):
  • Sexually Transmitted Diseases (STDs)
  • Contraception & Prenatal care
  • Substance abuse
  • Mental health services

⭐ In a true emergency, a physician can and should treat a minor without waiting for parental consent. This is a frequently tested ethical principle.

Mental Incapacity - Capacity & Caretakers

• Decision-making capacity requires the patient to:
  • Communicate a choice
  • Understand relevant information
  • Appreciate the situation and its consequences
  • Reason about treatment options
• Capacity is task-specific and can fluctuate; it is a clinical determination.
• If a patient lacks capacity, decisions are made by a surrogate.

Hierarchy of Surrogates (📌 Spouse, Adult Children, Parents, Siblings - "SACS")

1. Healthcare Proxy (designated in advance directive)
2. Spouse / Domestic partner
3. Adult Children
4. Parents
5. Adult Siblings
6. Close friend / relative

⭐ Capacity vs. Competence: Capacity is a clinical judgment made by a physician for a specific decision. Competence is a legal state determined by a court. A patient can lack capacity for a complex medical choice but still be legally competent overall.

Exceptions & Emergencies - Consent Under Pressure

• Emergency Exception: Implied consent is assumed if treatment is needed immediately to prevent serious harm or death, and the patient is incapacitated.
• Therapeutic Privilege: Very rare. A physician may withhold information if its disclosure would cause severe and immediate harm to the patient. Must be documented.
• Waiver: A capacitated patient may voluntarily waive their right to informed consent.

⭐ In a true emergency, the law operates on the presumption that a reasonable person would consent to necessary, life-saving medical intervention.

High‑Yield Points - ⚡ Biggest Takeaways

• Minors generally lack decision-making capacity; obtain parental consent and the child's assent whenever possible.
• Key exceptions for minors include emancipated status or specific care like contraception, STIs, and substance abuse.
• A diagnosis of mental illness does not automatically equal incapacity; it must be formally assessed.
• If a patient lacks capacity, decisions are made by a surrogate decision-maker or advance directive.
• In true emergencies, life-saving treatment can proceed without consent.