Virginia: 14 is old enough to decide on medical treatment

The governor hopes "Abraham's Law" will be a model for other states.

By — Posted May 7, 2007

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Virginia amended its child abuse law in late March to allow parents and children 14 or older to refuse medical treatment for a life-threatening condition. Most physicians and ethicists say the law is an appropriate acknowledgment of teenagers' role in medical decision-making, but some argue that it ultimately might limit adolescent rights.

The new law says parents cannot be charged with medical neglect if the decision to refuse a particular treatment for a life-threatening condition is made jointly and in good faith by the parents and a child who is 14 or older and "sufficiently mature to have an informed opinion on the subject of his medical treatment." The bill passed the Senate 29-10 and the House of Delegates 93-1 in late February.

Douglas S. Diekema, MD, MPH, director of education at Treuman Katz Center for Pediatric Bioethics at the University of Washington School of Medicine, said the law recognizes the changing view of children's medical autonomy.

"There are data that support 14 as the age at which most children acquire the ability to make reasoned decisions regarding medical issues," Dr. Diekema said. "If a child who is 14 or older and that child's parents agree that further aggressive treatment of a cancer or that a third liver transplantation, for example, is not in his or her best interests, that decision should be respected."

Dr. Diekema said the proper role for the courts in such cases is to ensure that the child freely decided to refuse the treatment and understands that the likely consequence is death.

The bill was dubbed "Abraham's Law" after Starchild Abraham Cherrix, a Chincoteague, Va., 17-year-old who has Hodgkin's disease and refused to undergo a second round of chemotherapy and radiation in February 2006. He and his parents opted for the Hoxsey method, an herbal treatment the American Cancer Society says has no scientific evidence of efficacy.

Cherrix's parents were charged with medical neglect, and a county social service agency sought a court order to force Abraham to receive the recommended treatment. Though the 20-year survival rate for Hodgkin's is 75%, the Cherrix family said the first round of treatment left the 6-foot-1-inch Abraham bald, feverish and so weak he struggled to walk from the car to the house or play with siblings.

The family put up a legal fight, and in August 2006 reached a court-ordered compromise that allowed Abraham to give up on the chemo if he agreed to see a board-certified Mississippi radiation oncologist open to alternative treatments.

"A law-abiding family in the Commonwealth of Virginia was being attacked by the same government that should be protecting them," said Republican Delegate John J. Welch III, DC, PhD, who sponsored the bill.

Dr. Welch said no other state's laws so specifically lay out teenagers' rights to refuse medical treatment and hopes "that legislatures in other states will take this thing national."

Democratic Virginia Gov. Tim Kaine said the statute is significant for health freedom in Virginia and could serve as a model for other states. "This measure strikes the appropriate balance between the rights of parents and a mature child to make informed medical decisions, and the responsibility of the state to protect the health and safety of children," he said in a statement after signing the bill.

The national landscape

Most states treat children younger than 18 as adults -- including for consenting to medical care -- if they are legally emancipated, living independently, serving in the military or married. Also, for cases such as sexually transmitted diseases and pregnancy, minors can independently accept or refuse treatment.

An evolving legal principle spelled out in case law but not necessarily in state statutes is the mature minor doctrine, which courts have used to allow children younger than 18 to make medical decisions if deemed mature enough to understand and appreciate the risks and benefits. While it is unclear whether that doctrine would have won the day in the Cherrix case, some experts worry that the new law --believed to be the first of its kind -- could weaken children's rights.

"The idea of basically shackling a child to undergo treatment against his own adolescent values and that of his parents really sounds medieval," said Marcia Levetown, MD, an expert on pediatric and palliative care ethics. Specifying an age for maturity, she added, "is limiting as opposed to enabling the freedom of children in these settings." As originally written, Abraham's Law did not include an age limit, but it was later added.

The Virginia Chapter of the American Academy of Pediatrics opposed the new law, arguing that it was too vague and amounted to a watering down of the state's child abuse and neglect statute. The Medical Society of Virginia did not take a position.

The AMA Council on Ethical and Judicial Affairs is preparing a report on pediatric decision-making for consideration at the AMA Annual Meeting in June. The American Academy of Pediatrics has policy saying doctors should seek the "assent" of older children, and "give serious consideration to each patient's developing capacities for participating in decision-making, including rationality and autonomy."

Cherrix still refuses chemotherapy. He discontinued the herbal treatment, but recently underwent another round of radiation to target five new tumors, said The Virginian-Pilot.

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