Box 2 Background on respect for autonomy among adolescents

HCPs have a duty to respect patient autonomy. However, the extent to which respect for patient autonomy applies to children and adolescent patients is debated. This is due to the underdeveloped capacities of young people, and their developing ability to understand medical information and weigh it up effectively to make fully informed decisions about their health. How HCPs can support and facilitate the development of autonomy among younger people in medical contexts is also debated.

In paediatrics, obtaining assent from a child involves explaining a medical procedure or treatment in an age-appropriate manner and ensuring that the child understands and agrees to the plan, even if parental consent is also required. This process respects the child’s developing autonomy and involvement in their own healthcare decisions.

In clinical ethics, there is ongoing debate about how to implement ‘assent’ among paediatric patients, with a lack of consensus on appropriate guidelines. The American Academy of Pediatrics suggests that “active agreement” may be suitable from the intellectual age of 7, with “assent” applicable between ages 8 to 14, though it ultimately leaves the decision to the discretion of healthcare providers. This flexibility allows for contextual judgments [19], but excessive interpretative latitude might lead to inconsistencies in how standards are applied, potentially neglecting the child’s role in decision-making. Some medical ethicists argue against a single predetermined age for assent, advocating instead for decisions based on factors such as the complexity of the medical intervention, the child’s maturity, and their familiarity with clinical settings [20]. Some evidence-based approaches suggest that children over 12 may have the capacity to understand and reason about medical information, though this is complicated by evidence indicating that adolescents may have underdeveloped executive functioning, making them more prone to underestimate risks [21]. Adapting the MacArthur Competence Assessment Tool for Clinical Research– a validated instrument for gauging adult competence to participate in research– Hein et al. [22] investigated the correlation between age and children’s capacity to provide consent, and found that children over the age of 12 are capable of understanding and reasoning about medical disclosures, concluding that currently established ethical and legal age limits for informed consent are unreasonably low.