Rachel: BBE Podcast Final Draft

The age of consent in bioethics is a prominent issue that is gaining significance as societal norms evolve. This debate covers various critical areas such as gender reassignment, reproductive health treatments, vaccination choices, and mental health interventions. Informed consent is a cornerstone principle in medical ethics, but minors generally lack the capacity to make life or death decisions independently. Emancipated minors, typically aged 14 to 17, have legal autonomy to make such decisions. In emergencies where parents are absent, physicians have decision-making authority. Parental consent is usually required for vaccination, but some states allow adolescents as young as 12 to consent independently. Minors can participate in clinical trials if the study focuses on pediatric subjects and parental consent is obtained. Dr. Petra Howitt, a family care physician and OBGYN, shares her insights on the age of consent in the medical field and discusses her journey in the medical professi Welcome back to Coffee and Consent, brewing bioethical discussions. I'm Rachel Baer, and I'm thrilled to guide you through today's episode. The age of consent stands as a prominent issue in bioethics, gaining increasing significance as societal norms evolve, granting minors greater autonomy. This dynamic debate encompasses various critical areas, from gender reassignment to reproductive health treatments, vaccination choices, and mental health interventions. Today we dive into the age of consent concerning life-saving treatments, vaccines, and clinical trials. I'll share insights from my research and engage in lightning conversations with the esteemed Dr. Petra Howitt. My exploration into the age of consent has revealed that the laws and perspectives surrounding the age of consent for life-saving treatments, vaccines, and clinical trials often presents clear-cut decisions facilitated by families with medical guidance. So what challenges do bioethicists encounter when navigating age of consent laws? Informed consent emerges as a cornerstone principle in medical ethics, encompassing decision capacity, documentation, disclosure, and competency. So what challenges do bioethicists encounter when navigating the age of consent laws? Informed consent emerges as a cornerstone principle in medical ethics, encompassing decision capacity, documentation, disclosure, and competency. The issue of whether minors can provide informed consent for life-saving measures, vaccines, and clinical trials hinges on their decision-making capacity and competency. Typically, most children lack the capacity and competency to make life or death decisions independently. This results in the appointment of a surrogate, often a parent or guardian. Exceptions arise when a minor is emancipated, granting them legal autonomy to make such decisions independently. This became a focus of my conversation with Dr. Howitt, with her background as a family care physician and a current OBGYN. She brings valuable insights, having assisted numerous emancipated patients. Emancipation, which can be petitioned by minors aged 14 to 17, grants legal adult status, with pregnancy in some states serving as an automatic trigger for emancipation. Before we dive into Dr. Howitt's professional perspective, let's establish some groundwork on these important talks. Firstly, the age of consent for life-saving measures. In emergencies where parents are absent, physicians wield decision-making authority, guided by the principle that children inherently desire to live. While rare, the Supreme Court ruling in Prince v. Massachusetts in 1944 mandates treatment for minors overriding parental objections if refusal would result in significant harm or death. Special cases like these are examined by an ethics committee, but do not have any state laws to guide their verdict. Exceptions to parental consent exist for mature minors in select states, empowering them to make their own life-saving treatment decisions. Next, let's tackle vaccines. Children under the age of 18 typically require parental consent for vaccination. However, recent debates, particularly amid the COVID-19 pandemic, have spotlighted adolescents' rights to self-vaccinate. While parental consent typically governs, some states and local jurisdictions afford adolescents as young as 12 the autonomy to consent to the COVID-19 vaccination independently. Notably five states, Alabama, Iowa, North Carolina, Oregon, and Tennessee, currently allow adolescents aged 12 and older to consent to the COVID-19 vaccination without parental approval. With certain cities like San Francisco and Philadelphia also enacting local statutes to facilitate independent vaccination. Lastly, and probably most simply, clinical trials present the least contentious area. Minors under the age of 18 typically cannot participate unless the study focuses on pediatric subjects, in which case parental consent is mandatory. With all of this groundwork laid, let's dive into my conversation with Dr. Petra Howitt. Hi Petra, how are you doing? Pretty good. How are you? I'm doing amazing. Thank you so much for being willing to take part in this podcast. I'm so excited to interview you and get your two cents on age of consent in the medical field. Absolutely. Glad to help. I'd like to start out with a little bit about you, about your journey to medical school and what your profession is. Yeah, I'm a family physician and I have been very fortunate to work in private practice for the first 12 years of my career. And after that I switched into women's health in the OBGYN department. So now for the last 12 years, I have worked in only women's health and that's where I'm still at right now. So that's been kind of my career in a nutshell. And what made you choose your two specialties? That's a good question. You know, I actually always wanted to have a job that didn't bore me and that sounds kind of funny, but I felt that family practice was, you know, such a great variety in medicine itself. It was not always the same, you know, and I was debating whether I should go into pediatrics or family practice. But then I just saw that in pediatrics, if you work in an office, it seems very monotone. You would see the same pattern every day, like ear infection, cough, ear infection, cough. And it was just a very monotone picture. And that's what I thought when I was, you know, young in medical school. And so when I, you know, rotated with the family practice department, it was so much more fascinating and interesting that you had the broad scope of practice with, you know, the little newborns all the way to the elderly. And you know, I just enjoy all the different stages. I enjoy talking to people, the young ones and the elderly. So I think that's why I went into it. That's awesome. And what kind of sparked the transition into Foley Women's Health? It was a change in location. We moved from the East Coast to California. So first, you know, I was in New Jersey. And when we moved to California, I knew I wanted a job that didn't involve delivering babies in the middle of the night anymore. So that made me look for a job that was, you know, just office space. And I just stumbled across the job with Kaiser that was, it was actually very unique in this area where we moved to. This doesn't really exist anywhere else, this special job that I have right now, family practice within the Department of OBGYNs. And you know, the reason for that is that Kaiser is very innovative and allows the physician because it's a physician-owned company and allows the physician to be creative and create new things within their own department. So my now best friend, she was the one who suggested, hey, you know, we need help seeing patients in the office because us as OBGYNs, we are always out delivering babies, we're doing surgeries. So we need more support in the office. So why don't we hire, you know, family physicians who are interested in doing that? And so it was a model that they tried out for the first time and just they posted the job. I just happened to come across it. So that's how it came about. Sounds like a great opportunity and also that you kind of had the opportunity to pioneer your position. It speaks so much to your professionalism as a doctor. Yeah, and it's, you know, we're five family physicians now in our region here that work within the OBGYN department that has worked out great. We have had great support and, you know, we help each other, obviously, and great teaching from the OBGYNs. And also we teach them about stuff that they don't, you know, have training in. So I think it's a really great work relationship that we have. You know, I mean, I've always believed in having, you know, a really good relationship with all my specialists that I work with because we all know different things. And if we all collaborate well together, then, you know, we can do so much more for our patients in general. So this is, you know, a little model that should be really expanded into a greater model. And so, yeah, we've kind of been working on that. Definitely. Yeah, I think it's a lot easier to go to work and work hard and innovate when you're part of a beautiful family and a great atmosphere. And it sounds like you found that at Kaiser. Yeah. I am curious if the age of consent was ever a focus of your medical schooling or a focus of kind of your integration into Kaiser. You know, and it was an interesting thought process that I had when you had asked me to do this interview. It was never really discussed much from a legal perspective, you know, in medical school and such. We, of course, always talked about it from the Hippocratic Oath. Right. So what is a relationship between the doctor and the patient stays between us. And that doesn't change whether somebody is really young or, you know, really old, you know, less than 18 years of age or over the age of 18. And so I just kind of have to think about that. The legal aspect of it really doesn't enter that much into our fear, more so the Hippocratic Oath in terms of we protect patients, you know, from that aspect. Right. So the other thing that's very interesting that I wasn't really that much aware of is that state to state, there are so many differences with emancipation, for example, that I had a different, you know, upbringing, so to speak, in New Jersey with emancipated minors than, you know, is the rule here in California. So those were all different patterns that, you know, I should really be aware of as a physician. However, they really don't play that much of a role in my daily practice because most of the stuff that I practice is based on the Hippocratic Oath and HIPAA laws. You know, you're familiar with the HIPAA laws that keep patients' privacy and data privacy for the patient really locked. And they're not they're the most important ones that don't get breached. But to get back to your question, the legal age for, you know, where the patient decides for themselves with vaccines and, you know, things like that is 18 in, you know, my mind. Yeah. As a physician, you're 100 percent right. I think that your biggest obligation is to the patient. And I think that seeing it from the Hippocratic Oath perspective is so important. You guys are the pillars of the medical field. And I think that that's why my capstone exists, why bioethicists exist, is because that's kind of their job. If there is any discrepancies between a parent and a minor, that's where kind of other professionals come in. And I think that you're so right. You're your first responsibility is to your patients. I think that it's amazing that you've kept that perspective for the entirety of your career. Absolutely. And, you know, I'm thinking about situations where I've had ethical difficulties, you know, where a minor wanted something and the guardian wanted something else for them. And I cannot even give you an example of a conflict that I personally have had as a physician. Well, first of all, I think it doesn't happen that often, thankfully. Like you said, there is the ethics committee that, you know, certain cases will get referred to. I think there's, you know, multiple reasons for that. First of all, I am not in the hospital, you know, where life and death is at stake and different people have different ideas about when to withdraw life support, for example, in the ICU. So that is not my daily, you know, bread and butter. And also, I think in my situation, you know, I just I believe in open communication. And so when there is a discrepancy of what the child wants versus what the adult is suggesting for them, you know, we talk about it and some of those discussions are difficult. But, you know, the most important things is to listen to to both sides and to just understand where they're coming from, to, you know, to have empathy for both of them and just to discuss it in a setting where both are present and try to, you know, really help them out to understand each other and then to also present information to them in a way that they can understand the medical part of it, you know, in a normal way, not in a scientific way, but to kind of level, you know, to their understanding and you really to understand why why it's important for them, why I'm suggesting something. And so I think that's mostly the reason that I have not had difficulties, because that is really important to me that my patients understand where I'm coming from and that I understand why they're feeling a certain way and where they're coming from. Definitely. Well, I think that your patients are very blessed to have a physician that's willing to really take the time and hash out all of the hard topics and just discuss everything, because that's something that we kind of explored when we started this podcast. We said that discussion is at the root of every bioethical issue. And I think that having those hard, difficult conversations and having your expertise there as well is something that not every family gets. So I think that they're very blessed to have you. Well, it takes more time. That's the downside to it, right? It just takes extra time. But if you do it well and give them the feeling from the get-go that you're there to help them and you're there to listen to them, it actually opens the doors from the beginning of the visit. And it doesn't take as much time as most people think. I do remember in our discussions prior to this call that you had mentioned you treating a couple of legally emancipated children because they're pregnant and you're in women's health. I was wondering if there are any special considerations when you're treating someone who's legally emancipated, how your job kind of changes in that situation. So the interesting part about that is that the states regard the emancipation differently. When I practiced in New Jersey, as soon as a minor became pregnant, they became emancipated. OK. And in California, that's not the case. So in California, a child is emancipated if they've moved out of the home and are under no financial support of the parent anymore or if they're married. But they're not emancipated when they're pregnant. So that was an eye-opening difference to me. And, you know, the interesting thing is that most of the time in California here, the parents are involved in helping their, you know, young ones who are pregnant with the pregnancy. They are supportive. We have had good support and good outcomes. In New Jersey, I definitely saw that the younger teen pregnancies were alone. They did not have parental support. And I didn't really realize the difference as much until I did see that the state laws were different. And now in retrospect, I am thinking like, oh, wow, actually, that is true. My teen pregnancies in New Jersey, they mostly came by themselves. They didn't have a parent. Do you think that the laws kind of have a bearing on whether the women feel alone in that respect, or do you think that it's more a cultural difference between New Jersey and California? You know, and that's exactly where my thought process was going. I wonder if because of the way the law is so different, when they grow up in that environment, if that makes the women who get pregnant so early feel differently because they're always kind of living with the impression like, oh, if I get pregnant, I'm emancipated. I'm on my own. Whereas here, the expectation is different. As long as I stay at home, my parents are supporting me whether I'm pregnant or not. It could be that that is just pre-programmed, so to speak. I think that might have a lot to do with it. Kind of in those situations when there are or are not parents present or there may be disagreements between the pregnant minor and the parents, do you often find yourself having to set your personal opinions to the side, or do your professional and personal opinions align for the most part? You know, that's a really good question. Of course, we, you know, as physicians, we're humans. We have opinions. We have feelings, you know, empathetic feelings most of the time. Over the years, you know, you treat patients and you have to really put your own feelings aside, especially when it comes to if you want to word it as such judgment, right? You cannot judge your patients. You have to really have a blank plate. You have to keep an open mind. And, you know, I've been doing this for 25 years now. And so I hope that I have, you know, really gotten to the point where I do not have my personal feelings influence any decisions I make or any advice I give to my patients because they don't deserve that. They deserve the pros and cons presented to them in a neutral fashion. My patients ask me, what would you do? And that's a really, really tough question because you just can't answer that for them. You know, I am not them. I'm not in their shoes. So I can't really tell them, listen, I would definitely do this. You know, I cannot give them that advice. I can just tell them this is what happens if you do this. This is what happens if you do that. Or these are the pros and cons, basically. So I try not to, you know, have my emotions or my biases, so to speak, in any of these encounters, if you want. Yeah, I think that that is such a blessing for patients as well. I know in my experiences, there was an instance where I was supposed to get surgery on my arm when I was an athlete as a child. And my surgeon told my mom, if it were my daughter, I wouldn't do it X, Y, Z. And I think that that had a huge bearing on her decision to kind of steer away from surgery. And that was the end of my softball career, so to speak. So I think that that's something that definitely really stuck with me because you're so right. I think that your patients sometimes are coming to you in vulnerable positions. It's beautiful that you kind of have the ability to step out and be like, no, you have to make this decision for yourself and just kind of give them all the tools to to do so and kind of use their own brains and their own ideologies and their own backgrounds to make those decisions. Exactly. Because it's not about me. That's what I always say. And I say that to my patients, too. Listen, this has nothing to do with me. It's not about me. This is about you, your body and your life. And you are the one who decides what's going to happen next. You have to live with that decision. That's all on you. And, you know, some patients are really upset by that because they're like, well, you're the expert. I'm like, yes, I'm the expert who's supposed to tell you the pros and cons and inform you. But I am not the one who has to live with what's going to happen afterwards. I'm here to help you and I'll walk with you. You know, so it's important that people understand that. I know we already discussed this just a bit. You kind of said that discussion is your way of kind of weeding out any disagreements. But how do you approach a situation where there's a disagreement between a child and their guardian? Yeah, I do think that depends on the subject matter as well. After the discussion, I will often present them with the resources that are available, depending on what it is. Counselor, you know, support groups, information. And then, you know, I tell them some decisions you can't make on the spot. You have to discuss this with each other. You need to think about it. And I'm going to have you go home, think about it. And then I need you to call me tomorrow morning and let me know what your decision is or in a week or whatever it is. Right. So because, you know, who can make a decision in two minutes? You can't. I mean, that's if it's a really big decision. Right. So some some things, they just need time. That's most of the time how we leave it off. But I never leave them stranded or on their own after that, because the follow up is important that, you know, they know that somebody cares and somebody is there to help them. So I think that has helped a lot with with difficult things, especially in OBGYN. You know, somebody had a miscarriage and they're not sure about how they want to proceed. And there are different options for medications or surgical options. And so those are decisions you can't make because they're so emotional. So those are the, you know, women I keep in touch with over the next couple of days. I'll, you know, send an email. I'll give them a call. They will call me back and, you know, things like that. I think in your profession that is so necessary, too, because being an OBGYN and helping women, especially throughout their pregnancies, such an emotional process, no matter which avenue you take. I think that it can either be extremely, like, emotionally positive process or an extremely emotionally negative process. I think that it's amazing that you you care enough and you find like that that follow up piece is a huge part of your job as well, not just the clinical piece. I think that's, you know, probably 90 percent of the job, actually, the emotional part. You know, I think most people don't realize that, that physicians, you know, do 90 percent of emotional care and then maybe 10 percent. Well, maybe I'm exaggerating. Maybe it's 60 percent. But, you know, because a lot of things in medicine you you can't really fix. You can only help support unless you're an orthopedic surgeon and you can fix an arm. I definitely agree. I think that speaking for myself, like when I go to the doctor, I'm looking for advice. I think that the biggest thing that I think about is like, OK, this person has gone through 12 years of schooling. They have an immense amount of education and they have the clinical pieces that I'm kind of missing to put my diagnosis together. I think that that advice is is what most people are coming for, but also just a little bit of support. So I think the fact that you are very intent on providing both of those things is amazing. Yeah, well, thank you. That's what brings you the most joy, too, though, you know, because you connect with your patient and establish a relationship. So that's what I enjoy the most anyway. I know that your profession doesn't work as much with age of consent for lifesaving treatments, vaccines and clinical trials. But I'm curious if there are any cultural or religious considerations that come kind of into play when you guys are discussing age of consent for lifesaving treatments, vaccines and clinical trials. Yeah, I was thinking about that. I have not really encountered that. What I'm aware of is the age of 18. And, you know, that could just mostly be because in women's health now, you know, we start seeing patients, they transition from the pediatrician to us at the age of 18. So when they're in our department and they get their shots, they're 18. And I was trying to remember if, you know, when they were in pediatrics, it was always the parent who had to give their nod, their consent for their kids to get their shots. So that's, you know, basically what's in my in my head. When they're admitted to the hospital, when they're pregnant, they are always asked, what is your, you know, what are your wishes? We call it what's your code status. Right. And so life sustaining measures. And of course, they're always full on life sustaining measures. And but that's also, you know, when they're 18, they answer that before the age of 18, that would be the parent. So and for clinical trials, I know that you have to be 18. You can't participate in most clinical trials under the age of 18 unless it's specified for children. And I'm sure then the parent has to sign as well. For cultural differences, I think that there would just be some hesitancy, maybe in certain cultures, but that might not be based on age. OK, well, maybe I think that those are all the questions that I have for you at the moment. I appreciate you sharing your experiences and your expertise. And I think throughout this discussion, my biggest takeaway is your care for your patients. And you saying that 90 percent of your job is the follow up and is just making sure that your patients are in a positive emotional state or at least have the tools to get there is so commendable. So all I can say after taking this class and hearing so many different cases where there have been difficulties, I think your patients are extremely blessed to have a physician like you. No, thank you, Rachel. It's really sweet. You can only, you know, you can only do your best and, you know, try to enjoy what you do and make it enjoyable for your patients as well. And, you know, that's what I try to do every day. So I'm having fun. I like making people happy. So the best way to do it. Thanks for listening to my interview with the esteemed Dr. Petra Howitt. This interview took place on April 13th, 2024. And now on to Table Talks. Hello, Josh, Brooke and Savannah, welcome to my podcast episode. Thank you so much for taking the time to discuss the age of consent for lifesaving treatments, vaccines and clinical trials. After listening to my podcast, do you guys have any major takeaways from my interview with Dr. Howitt? I'd say my most major takeaway from the interview especially was that your topic seems to be pretty black and white, like there aren't a lot of cases with a lot of controversy. The laws seem to be the same across every state, especially for clinical trials. It's very black and white. Yeah, that's something that I noticed as well throughout my research. I think that was probably my biggest roadblock. I do think that my three topics are three topics where most parents and minors can come to some kind of middle ground, come to an easier conclusion on their own. And I also think that the laws surrounding lifesaving treatments, vaccines and clinical trials really are set in stone. Yeah, I thought it was interesting in the interview that Dr. Howitt hasn't had any notable cases where a compromise couldn't be reached between a parent and a minor. Yeah, and I think that that definitely speaks to Dr. Howitt's personal practice and the way that she conducts herself as a family care physician. I think the discussion is that the basis of the way that she practices medicine. So overall, I think that the families are really lucky to have her as a medical professional. And I think that hopefully every doctor can learn a lot from the way that she handles her patients and any disagreements between a parent and a child. I am curious, though, what if your guys' parents said no to the COVID-19 vaccine? Would you guys get self-vaccinated and would you seek medical care on your own? For me personally, if I was a minor trying to get the COVID-19 vaccine and my parents said no, I definitely would try to seek medical care on my own. I know that in some states it is very easy for minors to get the COVID-19 vaccine without need of parental consent. I know also that it's not easy to access those states if you don't already live in those states because of how large the U.S. is. So if that's not an option, I would say probably I would go through either getting emancipated or trying to find another form of parental consent through maybe like a school counselor or something like that. Definitely, yeah. Emancipation was a huge topic of conversation between me and Dr. Hoet. I think that emancipated minors, whether they apply for emancipation or are emancipated on part of getting pregnant, they, for the most part, can make decisions for themselves, which I think is a great route for any minor who disagrees with the conclusions that their parents have come to. Do you guys think there should be more fluidity in the laws surrounding the age of consent for lifesaving treatments, vaccines and clinical trials? I'd say yes, especially for vaccines, just because in my research, I know there's like case by case cases where you can deem a minor as mature and they can essentially consent as if they were an adult. And I feel like for vaccinations, which seem pretty low stakes in terms of medical care, a minor could be mature enough more easily than like making any other medical decisions to decide to get their own vaccines. Yeah, I totally agree. In a state of emergency like the pandemic that we just experienced, do you guys think that the age of consent should be ignored? I'm going to say no, I don't think the age of consent should be ignored entirely. I think we can definitely benefit from more fluidity from the age of consent in a pandemic scenario, but completely ignoring it, I think, would cause more problems in cases where like children that obviously aren't mature enough to consent for themselves attempt to without fully understanding what they're doing. And then I think it's just it's not worth it. I agree. I think there are a lot of lawsuits in medicine, and I think this would just cause more lawsuits if minors have that much access to medical care. Yeah, I was going to my first answer was going to be yes, just because time of emergency makes me think it's time sensitive and it would be more beneficial to get everyone vaxxed right away. But I hadn't considered how it could change the precedent in the future for medical care for minors. Yeah, that was definitely something that I saw throughout my research. I think the COVID-19 pandemic definitely bent a lot of the age of consent laws because of the overall state of emergency. There were many states where a child could get vaccinated at the age of 16 or older or be deemed a mature minor so they could self vaccinate without having their parents consent. And I think the reasoning for this is just overall to benefit society and to protect the citizens of the United States. Do you guys think that minors should be allowed to participate in clinical trials? For example, a 14 year old has a kind of cancer where there is a new drug being tested. Do you think that they should be able to seek the treatment that hasn't been approved by the FDA? My first thought is to say yes, just because if they're seeking this treatment on their own, it makes me think that nothing else has worked yet. And in the case of like a disease like cancer that has like a high fatality rate, I think it should be even if they're a minor, their decision on where to go with their treatment because it's their life at that state at the end of the day. Definitely. I'm going to say no, if it hasn't been approved by the FDA, it means it hasn't been approved for adults, let alone children. And I think it needs to be tested on adults before children. Yeah, I agree with that. I want to say yes, because it's a child's life in danger. But at the end of the day, I think testing should be limited to adults, at least in the beginning. Yeah, and that was a conclusion that Dr. Howlett pointed out as well. In every state in the United States, the age of 18 is kind of the cutoff point. There is no testing of clinical trials on children. I think that that's put into place just to protect children in general. There are drugs that are involved in clinical trials that could be potentially harmful. And I don't think that children have the ability to really make that decision and fully understand what they're signing up for. The only exception to that rule is when a clinical trial is specifically modeled for minors, in which case parental approval is needed. I appreciate you all taking the time to discuss the age of consent for lifesaving treatments, vaccines and clinical trials. I think you guys brought up a lot of really valuable points surrounding this topic. And I loved hearing your two cents on the COVID-19 pandemic and clinical trial participation. Thanks for having us, Rachel. It was a pleasure. As we conclude today's episode of Coffee and Consent, Brewing Bioethical Discussions, it's clear that the age of consent in health care, particularly regarding lifesaving treatments, vaccines and clinical trials, is a multifaceted issue. Throughout this episode, we gained valuable insights presented by the esteemed Dr. Petra Howitt, including legal emancipation and conversational medical practice. We also explored various perspectives brought forward by my group mates, including the age of consent for COVID-19 vaccines, the fluidity of age of consent laws and clinical trial ethics. Throughout these conversations, one thing remains certain, the importance of ensuring the well-being and autonomy of minors in health care decision making, whether it's through the guidance of parents, the support of medical professionals or the empowerment of mature minors. Our collective goal is to navigate these challenging waters with compassion, integrity and respect for individual rights. As we continue to navigate the ever-evolving landscape of bioethics, let's remember the significance of informed consent and the necessity of an open dialogue. Discussion is at the heart of every bioethical issue. The more discussion is had, the closer we can get to the truth. Thank you for joining me on this journey of exploration and reflection into the age of consent for lifesaving treatments, vaccines and clinical trials. Until next time, I'm Rachel Baer and thank you for your interest in bioethics.