Guest Post: Who Calls the Shots?  Teens and the HPV Vaccine

Suchi Agrawal

Paper: Who calls the shots? The ethics of adolescent self-consent for HPV vaccination 

During my pediatric hospital medicine rotation, I stopped the team before we entered the room of our sixteen-year-old patient and her parents.  “Just a reminder, the patient does not want her parents to know she was tested for gonorrhea and chlamydia.”  After ensuring we were all on the same page, we continued with our routine of updating the family on the patient’s current care and treatment plan, all while making sure to honor the patient’s request.  This would strike no pediatric clinician as abnormal.

As medical students, we had been encouraged in our ethics course to notice and question ethical issues in the clinical setting.  I remember wondering why, though we could offer the patient diagnostic testing for sexually transmitted infections (STIs) in confidence, we could not offer the patient the HPV vaccine.  I began to wonder–if we could offer testing and treatment for STIs to adolescents without parental consent, shouldn’t it also be ethical to similarly offer medical services to prevent STIs in the first place?

Unfortunately, I soon realized there is no legal consensus or universal framework in the United States to allow adolescent self-consent to the HPV vaccine.  While every state has laws allowing minors to consent for diagnosis and treatment of STIs, consistent with ethical consensus established by numerous professional medical societies, the laws are less clear when it comes to prevention.  Some states have already taken steps to address this gap.  In 2011, Governor Jerry Brown signed into law AB499, which explicitly permits adolescents to consent to confidential medical services for the prevention of STIs, including the HPV vaccine. Other states that have laws similar to that of California include Alabama, Arkansas, Kansas, and Montana.  In Texas, Representative Sarah Davis proposed HB97-S which would allow minors to consent to vaccines that prevent cancer –including the HPV vaccine.

In our recent JME paper, we argue that there are strong ethical justifications for permitting adolescents to self-consent for the HPV vaccine.  Consequently, we advise other states to follow California’s lead and pass legislation to explicitly permit adolescents to self-consent for prevention of STIs, including receipt of the HPV vaccine.

This issue is important as HPV vaccination rates consistently fall short of public health goals.  Allowing for adolescent self-consent can remove a system level barrier to obtaining the vaccine.  Ethical support for adolescent self-consent comes largely from considering both the public health and individual benefits of the HPV vaccine in addition to respect for an adolescent’s developing autonomy.

The HPV vaccine provides both public health and individual medical benefits.  The vaccine protects against human papillomavirus – a sexually transmitted infection that can cause genital warts, cervical, and oropharyngeal cancers.  Thus, a vaccine protects both the individual and his or her sexual partners from preventable medical diseases.  HPV is responsible for a significant medical burden accounting for a total of 26 200 new cancers per year in the USA (17 400 women and 8800 men).

Furthermore, providers can strengthen the patient-physician relationship by establishing their role as a trusted resource for “sensitive topics” such as sexual health.  This relationship is important as the major causes of morbidity and mortality in adolescents are often due to sensitive issues, including unsafe sex, intoxication, interpersonal violence and depression, underscoring the necessity of permitting adolescents to approach these topics with a physician alone if necessary.  Negative consequences of the HPV vaccine are minimal, as large post licensure observational studies have confirmed the immunization’s safety.

Additionally, permitting adolescents to self-consent for HPV supports an adolescent’s developing autonomy.  Teenagers mature throughout adolescence and do not suddenly become capable of making their own medical decisions on their 18th birthday.  This concept is reflected in the UK’s ‘Gillick Competence’ standard, which guides whether patients under the UK’s age of medical consent (16) can consent to a medical decision.  Medical decisions with higher levels of risk or complexity, such as those regarding life-sustaining treatment, require adolescents to demonstrate a higher level of competence for decision-making than, for example, routine medical decisions with a low risk of harm.  We believe that consenting to the HPV vaccine is a low risk medical decision and that providers can assess an adolescent’s competence in making such a decision.  Furthermore, it is understood that minors possess autonomous decision making regarding diagnosis and treatment of STIs, and it is logical to extend this decision making to include prevention.

Permitting adolescents to self-consent for HPV vaccination therefore advances an important public health goal.  It is also consistent with the goal of encouraging adolescents to develop the capacity to make health decisions in their own best interest.  Unfortunately, however, existing state laws often do not address adolescent self-consent for HPV vaccination and other STI treatment, meaning many physicians may not currently be permitted to let adolescents elect HPV vaccination without parental consent.  Other US states should take action to pass laws similar to that of California so as to enable adolescents to help protect their health.

  •            No competing interests