Is the capacity to consent different from the capacity to refuse treatments and procedures in adolescence?

Martins, Guilherme Henrique; Eler, Kalline; Albuquerque, Aline; Nunes, Rui

doi:10.1016/j.jped.2025.04.004

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Review article • J. Pediatr. (Rio J.) 101 (4) • 2025 • https://doi.org/10.1016/j.jped.2025.04.004 linkcopy

Is the capacity to consent different from the capacity to refuse treatments and procedures in adolescence?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective The objective of this article is to broaden the discussion on the factors that constitute adolescent healthcare decisional capacity, ensuring that adolescents are recognized as capable of refusing treatments or procedures.

Sources Materials from different sources were analyzed, including articles from reputable databases and documents from government agencies, forming a purposefully selected sample. The research was conducted in two phases: document selection and reflective analysis, followed by a report. The discussion was approached from a phenomenological perspective, with reflections grounded in human rights principles.

Summary of the findings Healthcare decisional capacity must be sufficiently robust to allow adolescents to refuse treatments or procedures. It is essential to respect the right of capable adolescents to refuse treatments and procedures. Protecting the vulnerability of adolescent patients involves honoring their growing autonomy. Data from field research regarding the refusal of treatments and procedures in adolescence are scarce, which limits the scope of the proposed discussion.

Conclusions It cannot be argued that adolescents should have different abilities to refuse a treatment or procedure compared to those required to give consent. The importance of these skills seems to vary between these situations. This difference is justified by the need to consider potential harm to health, even though it could be argued that damage to health should be part of the bioethical deliberation surrounding the decision, rather than a factor in the assessment of decisional capacity.

Keywords
Decision-making; Adolescent; Bioethics; Clinical ethics

References	Consideration
Buchanan and Brock⁷⁸	For the child [and adolescent] to achieve the right to refuse, the capacity must be greater than the capacity to consent.
Pearce⁷⁹	A more rigorous assessment should be applied when evaluating a child's ability to refuse consent compared to assessing their competence to give consent.
Doyal and Henning⁸⁰	A competent adolescent has the moral right to decide whether to continue treatment or to cease it, especially in cases of chronic illness and terminal conditions.
Shaw¹³	The level of understanding required for an adolescent to make a decision is directly proportional to the risk-benefit ratio of the proposed treatment.
Stancioli⁸¹	Two criteria must be considered before decision-making power is granted to a teenager: preventing the legal system from becoming excessively complex and evaluating the risks associated with the decision-making process.
Annas²⁰	The right to refuse should prevail in the decision when there is no risk of death or severe harm to the patient's health.
Cave³⁵	The more severe the potential outcome, the higher the standard of proof [that assesses decisional capacity]
Michaud et al.²⁷	The adolescent patient's evolutionary capacity to make decisions is proportional to the complexity of the decision.
Manson⁸²	Consent and refusal have normative power with respect to adolescents, but refusals are limited by situations where serious harm may occur.
Kling & Kruger⁸³	Medical treatment should only be provided or withheld if the patient has given legal consent or refusal.
GMC¹¹	The harm to adolescents' rights must be carefully considered when overriding their refusal, ensuring decisions are made in their best interests.
Eler²²	Disregarding the adolescent's expressed wishes is only possible if the risks associated with their choice prove to be contrary to their best interests.
Skelton, Forsberg & Black¹⁰	It is important to protect adolescents from full responsibility for their decisions, which may mean that refusals associated with harm to health may not be normatively decisive.
Herring⁶	Harm must be prevented at all costs by the care team and legal guardians of adolescent patients.

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