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Informed Consent and Adolescents

Article  in  Canadian journal of psychiatry. Revue canadienne de psychiatrie · September 2005

DOI: 10.1177/070674370505000906 · Source: PubMed

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Review Paper

Informed Consent and Adolescents

Debbie Schachter, MD, FRCPC1, Irwin Kleinman, MD, FRCPC2, William Harvey, PhD, LLB3

Objective: To explore the doctrine of informed consent and the development of capacity in
adolescents with psychiatric problems to help clinicians better reflect on the relevant
ethical issues.
Method: We discuss the relevant literature and explore the role of psychiatric impairment
in adolescents’ ability to consent.
Results: In common law, there is no minimum age at which individuals are able to consent
to medical treatment and no age below which they are unable to consent. Adolescents’
right to self-determination is based on their ability to understand and appreciate the
information relevant to the medical decision and on their ability to consent voluntarily and
freely. There is a consensus in the literature that, around age 14 years, adolescents have the
cognitive ability to understand information necessary for consent. However, there are
limited empirical data regarding adolescents’ ability to appreciate the information and to
make a voluntary decision.
Conclusion: Clinicians need to involve adolescents in the consent process to the extent
possible and assess the elements of capacity to consent to treatment on an individual case
basis, recognizing that capacity may evolve as adolescents’ cognitive capacities and values
mature.
(Can J Psychiatry 2005;50:534–540)
Information on funding and support and author affiliations appears at the end of the article.

Clinical Implications
· Adolescents should be involved in the consent process to the extent possible.
· Capacity to consent to treatment needs to be assessed on a case-by-case basis.
· Empirical research is needed to further our knowledge in this area.

Limitations
· There are limited empirical data on adolescents’ capacity to consent.
· There is no gold standard for assessing competence.
· Standards for capacity assessments vary in clinical practice and empirical research.

Key Words: informed consent, adolescents, capacity, competency

n individual’s right to determine his or her medical treat-
A ment is ethically and legally fundamental in the patient–
physician relationship and reflects the underlying values of
beneficence and respect for individuals’ autonomy (or
self-determination) or well-being (1–3). The elements of a
valid informed consent include that the individual has the
capacity to consent, has received adequate disclosure of rele-
vant treatment information, and has given consent voluntarily
and freely (4).
The first element of informed consent relates to the individ-
ual’s capacity. “Capacity” (in legal terms) or “competence”
(in ordinary language and bioethics) may be defined in terms
of ability. To say that a person has the capacity or competence
to do something is to say that he or she has the ability to do it.
In this paper, the term capacity (or competence) will be used to
refer to the ability to give a valid consent or refusal to medical
treatment. Capacity is decision-specific; that is, it relates to
the specific treatment being proposed to a patient in a specific

534
W Can J Psychiatry, Vol 50, No 9, August 2005

situation under specific conditions. Capacity to consent to or
refuse a particular treatment represents the ability to under-
stand and to appreciate the information disclosed related to the
proposed treatment.
Mental capacity or competence is a prerequisite to informed
consent. There is no gold standard of competence (5). The
concepts of capacity or competence are normative or
evaluative. To say that a person has the capacity or compe-
tence to do something (for example, to make a choice or a
decision) is to say that the individual has the ability to do it;
that is, the person has met or surpassed a particular standard or
test (6). Whatever the apparently empirical nature of the stan-
dards or tests of capacity, the assessor’s application of those
empirical criteria to the relevant data (that is, patient responses
to assessment questions) requires the assessor to make a nor-
mative judgment (for example, that the patient is either
competent or incompetent) (7–9).
The content of these capacity standards varies among jurisdic-
tions, just as the tests may vary among practitioners (5). The
standards of capacity are typically stated to be the ability to
understand information relevant to making a treatment deci-
sion and the ability to appreciate the reasonably foreseeable
consequences of a decision or lack of decision (5). The ability
to appreciate the reasonably foreseeable consequences
involves patients’ insight, their awareness and understanding
that they have an illness, and their ability to apply the informa-
tion to their personal situation. For example, in the Regula-
tions under the Substitute Decisions Act, Ontario 1992 (10),
the Guidelines for Conducting Assessments of Capacity (10)
analyze that standard of appreciation as a normative, and not
only empirical, standard that has an affective element as well
as an element of choice. Competent persons have the ability to
realistically appraise the outcome of their choice and are able
to justify that choice or decision. Thus the Guidelines are
neither purely cognitive nor purely empirical.
The second element of informed consent requires that patients
receive an adequate disclosure of information. The informa-
tion disclosed should relate to the nature of the proposed treat-
ment, the expected benefits, the material risks and side effects
of treatment, the alternative courses of action that could rea-
sonably be pursued, and the likely consequences of not having
the treatment (4,11). The standard of disclosure is the infor-
mation that a reasonable person in the patient’s specific situa-
tio n w o u ld w a n t to k n o w to mak e a n in f o r me d
decision (12–14). The material benefits and risks of treat-
ment (12,13) must be disclosed.
The final element of informed consent is that the consent be given
voluntarily and free of force, coercion, or manipulation (15).
Although the informed consent process is sometimes
described or conceptualized as a discrete event, it is actually a
Can J Psychiatry, Vol 50, No 9, August 2005 W
Informed Consent and Adolescents
dynamic process occurring throughout the patient–physician
relationship (4). It begins with initial information sharing and
diagnosis and may be followed by further information gather-
ing, information sharing, and shared decision making. Thus
adolescents’ role in the consent process will likely evolve
over time, with their evolving capacity.
A patient’s ethical and legal right to consent to or refuse sug-
gested treatment is contingent on the patient’s capacity, com-
petence, or ability to do so. An authoritative or valid choice by
patients gives rise to correlative duties in third parties, such as
physicians, to not interfere with that choice and to assist
patients in securing their treatment goals. An authoritative or
valid choice need not be correct according to the ethical and
medical standards of a community or a health care profes-
sion (16). Competent patients have the right to decide what is
in their best interests according to their own value system.
Substitute decision makers, typically family members or other
legally validated persons, are permitted to consent or refuse
on a person’s behalf when that individual lacks the capacity to
make an authoritative choice (4). Even when patients are inca-
pable of giving a valid consent or refusal, they may have the
ability to assent or dissent (17). Hence, such patients ought to
be encouraged to participate in shared decision making, even
if their wishes are not authoritative. Adolescents may, at
times, be examples of such persons.
During adolescence, the period spanning age 13 to 19 years,
there is a gradual development of values and, with maturity,
an increasing ability to make self-defining or autonomous
choices (18). Adolescents may differ from adults in their per-
ceptions and attitudes toward risks and benefits and in their
increased involvement in risk-taking behaviour (19). Adoles-
cents may value risks and benefits differently from adults; for
example, they may attach more value to the immediate rather
than long-term consequences (19). There is debate about
whether adolescents feel less vulnerable to risks than
adults (20–22).
When are adolescents sufficiently mature to appreciate bene-
fits and risks, their own potential vulnerability to risks, and
their mortality to make authoritative medical decisions? There
is debate about when adolescents develop sufficiently stable
life goals and values against which to weigh information in the
context of medical decision making and whether they are suf-
ficiently mature and autonomous to consent to medical treat-
ment (18,19,23). Protective policies toward adolescents are
usually based on the presumption that adolescents differ from
adults in their capacities for reasoning and appreciation, as
well as in their choices, maturity, and behaviour (18,19).
Informed consent in psychiatry has been particularly impor-
tant and challenging for several reasons. In psychiatry, a
patient’s mental illness itself may intensify the physicians’
535
The Canadian Journal of Psychiatry—Review Paper
difficulty in weighing and balancing the values of patient
autonomy and patient well-being that ground the informed
consent process and the relationship with their patients (24).
Patients with psychiatric illnesses may be viewed as more
likely to choose badly, unwisely, or more harmfully than per-
sons without mental illness, possibly giving rise to a physi-
cian’s paternalistic view that patients’ well-being is to be
preferred to respecting their autonomy, as expressed through
their choices.
For example, there were early concerns cited in the literature
that adult patients who were treated with antipsychotic medi-
cation would discontinue treatment or relapse if informed
about potential side effects (25). Empirical data suggest that
patients with schizophrenia informed about tardive
dyskinesia have not experienced an increased rate of relapse,
medication discontinuation, or hospitalization (26). Further,
while the understanding of information is reduced among
schizophrenia patients with increased psychopathology,
many schizophrenia patients achieve the same level of under-
standing as medically ill control subjects (27,28). In addition,
there have been concerns about whether some patients with
depression are competent to refuse treatment (29).
Thus the informed consent process with psychiatric patients
challenges the caregiver to ensure that there are adequate mea-
sures to facilitate patient understanding and appreciation and
thereby maximize patient autonomy and well-being. The goal
is to respect and not interfere with patient decision making.
With respect to adolescents, the informed consent process fur-
ther challenges physicians’ ability to balance the promotion of
patient autonomy and patient well-being. When adults make
decisions that appear to be poor choices, these choices may be
understood to reflect the individual’s idiosyncratic view.
However, when adolescents make decisions that may cause
potential harm, additional concerns about capacity and matu-
rity may be triggered. Although the outcome of a medical
decision should not theoretically affect the determination of
capacity (30), in practice it may, and it is likely to have a stron-
ger impact when treating adolescents who may be thought, as
a group, to lack the maturity of adults (19). Thus working with
adolescents is likely to intensify the struggle within physi-
cians between paternalism and patient self-determination.
However, the informed consent process, as well as the
patient–physician relationship generally, should assist
adolescents in developing the capacity to make autonomous
choices.
The issue of who has authoritative decision making typically
becomes most clinically challenging when adolescents and
their caregivers (for example, a parent, guardian, or trustee)
disagree regarding treatment. The clinical challenge is two-
fold: it involves 1) determining whether the adolescent who is
536
faced with a treatment decision in fact has the capacity to
consent to or refuse the particular treatment decision and
2) working with the caregiver and adolescent in a manner that
is respectful to all. There is the challenge of involving care-
givers in treatment planning when the adolescent has the
capacity to make clinical treatment decisions and the recipro-
cal challenge of involving the adolescent in the treatment
decision to the extent possible when the adolescent lacks
capacity. In the latter case, the adolescent may be said to be
able to assent to or dissent from proposed treatment (17).
However, those assents or dissents are not authoritative; that
is, they do not ethically or legally bind physicians to accede to
the patient’s specific wishes.
Adolescence is a period during which there is a developmen-
tal shift toward increasing freedom or independence from par-
ents and families; the informed consent process, as well as the
patient–physician relationship generally, should assist ado-
lescents in developing the capacity to make autonomous
choices. It is also during adolescence that the ability for
abstract thinking becomes more fully developed.
Capacity in Adolescents: Empirical Studies
Factors in children that are said to be associated with under-
standing the information necessary for consent include age,
intelligence, experience with illness, cognitive development,
and linguistic background (31–36). Regarding age, there is an
emerging consensus from a developmental perspective that
adolescents aged 14 years and over can understand informa-
tion necessary for valid consent (31–36). There are fewer data
in the empirical literature.
Several studies examined adolescents’ understanding of
information disclosed related to medical interventions and
their reasoning process. In hypothetical treatment dilemmas,
investigators examined the understanding of information and
reasoning of subjects aged 9, 14, 18, and 21 years. The investi-
gators found that the adolescents aged 14 years did not differ
from adults (37). The authors were unclear whether the results
of these hypothetical situations would apply to children with
actual disorders.
In another study using hypothetical vignettes, adolescents
aged 14 to 18 years with mental health difficulties resembled
age-matched control subjects in their understanding of infor-
mation, but they performed more poorly in reasoning, with
verbal IQ correlating with understanding (38). Kaser-Boyd
and others studied individuals aged 10 to 20 years with a range
of emotional or learning difficulties and examined their
understanding of the benefits and risks of individual problem-
solving therapy after an information session (39). Most sub-
jects identified at least one risk or benefit of therapy, with
those having had therapy identifying more benefits and risks
and those being referred for therapy identifying more
W Can J Psychiatry, Vol 50, No 9, August 2005

benefits (39). Those aged over 14 years were more likely to
believe that therapy might help them learn something,
whereas those aged under 14 years were less knowledgeable
regarding potential benefits of therapy.
Casimir and Billick found that intelligence correlated with
knowledge of the legal aspects of hospitalization but not with
more general knowledge about psychiatric hospitaliza-
tion (40). In another study, Billick and others found that com-
petency, as determined with a questionnaire, correlated
significantly with both age and reading level among pediatric
patients aged 5 to 18 years and that most subjects were defined
as competent at age 12 years (41). However, in both studies,
subjects did not receive a structured disclosure, and it is
unclear whether all subjects were adequately informed.
The role of psychiatric illness on adolescents’ ability to under-
stand information to consent to psychiatric medications prior
to treatment has not been studied. A series of studies, how-
ever, have examined hospitalized children’s and adolescents’
knowledge about psychiatric medications after disclosure and
after medication was initiated. Children had varied diagnoses
and were taking various medications. Children’s knowledge
correlated with verbal IQ but not with age (42). Children
learned the name, dosage, target symptoms, and benign side
effects but not the more serious side effects or treatment alter-
natives; those receiving a more intensive intervention had
more knowledge (43). There was no significant difference
between parents’ and adolescents’ knowledge (44). One diffi-
culty in interpreting these findings is that patients’ knowledge
was assessed after they received medication, which might
have affected their knowledge. It is unclear what would have
been known after disclosure alone (the situation patients are
typically in), prior to commencing medication treatment. It is
also unclear how to interpret the finding of no difference in
knowledge between adolescents and parents, because there
was no control parent or adolescent group.
Ambuel and Rappaport studied the reasoning of girls and
women facing pregnancy decisions in groups aged under 15
years, 16 to 17 years, and 18 to 21 years (45). For those con-
sidering abortion, there was no difference between groups in
terms of their reasoning about the pregnancy decision, sug-
gesting similar levels of competence to justify choice. How-
ever, for those not considering abortion, the reasoning of girls
aged under 15 years was less well developed than for those
aged 16 to 17 years or those aged 18 to 21 years, suggesting
that, for these adolescents, justification was less well devel-
oped than that of the older individuals.
Notwithstanding the limitations of the aforementioned stud-
ies, the literature does seem to support the consensus that ado-
lescents’ understanding of information after they have
received treatment is similar to parents’ understanding in the
Can J Psychiatry, Vol 50, No 9, August 2005 W
Informed Consent and Adolescents
same circumstances; that is, it is similar to the understanding
of a typical surrogate decision maker where adolescents lack
capacity. Adolescents with mental health difficulties seem to
have understanding similar to control subjects. Intelligence
correlates with adolescents’ understanding, similar to what is
observed in adults (46).
The data with respect to reasoning, which is one dimension of
appreciation, are less conclusive. There have been fewer stud-
ies focusing solely on appreciation, the second element of
capacity. Appreciation involves the realistic appraisal of the
decision outcome and the justification of the particular choice.
In the absence of operational guidelines for evaluating the
appreciation element of capacity, the assessor must make a
subjective value judgment as to whether a threshold has been
reached in terms of appreciation. Thus, insofar as the determi-
nation of appreciation is a normative or evaluative process
and contains an affective element, its determination is even
more difficult than the assessment of understanding.
Children’s development occurs not only in terms of cognition
but also in terms of affect (or emotion) and values. Adoles-
cents’ ability for abstract thinking, foreseeing consequences
of their treatment choices, and appreciating their illness and
its course with or without treatment likely evolves during ado-
lescence. Achieving the necessary maturity to appreciate
treatment decisions is a process that likely takes place over
time. In particular, it is unclear how well adolescents with psy-
chiatric problems appreciate their disorder and treatment rec-
ommendations and whether this situation is unique to
adolescents or applies to adults as well.
Disclosure of Relevant Information to Adolescents
There are no empirical studies examining different disclosure
formats for valid disclosure to adolescents. To facilitate and
potentially maximize adolescents’ capacity and evolving
capacity, it is recommended that the information disclosed be
presented in a way that facilitates their understanding. Read-
ing material, if provided, should be suitable to adolescents’
reading achievement. For adult reading material, a reading
level of Grade 5 to 6 is recommended (47). For adolescents,
we recommend a similar level.
The manner in which information is shared with adolescents
requires consideration. Information can be transmitted with
various media, including written material (pamphlets or
books), orally presented material, or audio-visual media such
as television or videotapes (48). Information handouts are
more effective when discussed with a professional than when
read independently (48). While various methods can, and
likely should, be used to ensure optimal understanding, clini-
cians will need to assess whether the information is
understood and appreciated.
537
The Canadian Journal of Psychiatry—Review Paper
Voluntary Nature of Consent During Adolescence. For con-
sent to be valid or authoritative, it must be given voluntarily
and free of coercion (15). For both adults and adolescents,
obstacles to voluntary consent can come from health care pro-
fessionals or important persons in patients’ social environ-
ments (4). Clearly, physicians should not coerce patients in
any way with respect to treatment decisions. Treating profes-
sionals should not retaliate against or threaten to withdraw
treatment from a patient who does not follow their recommen-
dation. How one assesses the impact of threats from family
members, teachers, or colleagues on an adolescent’s decision
making is particularly important for adolescents. Grisso and
Appelbaum suggested that threats that arise from outside the
treatment team, such as when people make demands on
patients as conditions for involvement in ongoing relation-
ships, should not invalidate the voluntary nature of con-
sent (4). However, adolescents are usually more dependent on
parents’ for their well-being than are independent adults and,
therefore, would be potentially more unable to make inde-
pendent decisions when threatened by family members. How-
ever, this is a conjecture and needs to be more fully examined
within clinical situations.
Roberts claims that the ability to make voluntary decisions
develops throughout adolescence (49). It has also been sug-
gested that adolescents may have a greater tendency to con-
form than adults; thus younger adolescents may not be truly
able to provide voluntary consent. However, adolescent youth
with oppositional traits and disruptive behaviour disorders
might be hypothesized to have a greater tendency to oppose
adults’ recommendations. This determination would have to
be made on a case-by-case basis.
There have been 2 empirical studies of voluntary medical
decision making with hypothetical vignettes displaying vary-
ing degrees of parental influence. Scherer and Reppucci
found that the decisions of adolescents’ aged 14 to 15 years
were influenced by parental input (50). The impact of parental
influence on decision making was reduced for the more seri-
ous vignettes. In a subsequent study, Scherer compared ado-
lescents aged 14 to 15 years with children aged 9 to 10 years
and with young adults aged 21 to 25 years under conditions of
varying parental influence (51). Differences emerged across
age groups and according to the severity of the medical
vignette. For the serious medical vignette (that is, a kidney
donation), both adults and adolescents were more likely to
maintain their conviction in the face of parental influence than
were children. There was a trend for young adults to maintain
their original decision, compared with adolescents, but this
did not reach conventional levels of statistical significance.
Adolescents, however, were more likely to maintain their
original decisions than were children. For the less serious
vignettes, such as those dealing with tonsillitis or wart
removal, all groups were as likely to change their decisions in
the face of increased parental influence.
In Ambuel’s study of girls and women facing pregnancy
decisions, the ability to make a voluntary decision was com-
pared among those aged under 15 years, 16 to 17 years, and
538
18 to 21 years (45). For those considering having an abor-
tion, there was no difference in voluntary decision making
among groups. However, for those not considering undergo-
ing an abortion, girls aged under 15 years had less voluntary
decision-making ability than those aged 16 to 17 years or
those aged 18 to 21 years.
Consent in Canada
In Canada, the age at which the law recognizes a child to be
capable of making valid health care choices varies across the
provinces and territories (11,52,53). In common law, there is
no specific age at which individuals are capable of consenting
to or refusing treatment and no specific age below which they
are unable to give a valid consent or refusal (54). The child’s
right to consent depends on decision-making capacity (55). In
some provinces, the common law of consent is codified; in
other provinces, an age of consent is stipulated in legisla-
tion (56,57). In most jurisdictions, laws relating to consent can
be found in several statutes, and there might be complex rela-
tions among them (11). Child welfare legislation may be of
particular concern when a mature minor refuses medically
necessary and life-saving treatment (11,18,53). Clinicians are
advised to be familiar with the relevant statutes and common
law decisions in their jurisdiction (11). This complexity of the
law related to an adolescent’s capacity to make health care
decisions reflects the tension between society’s recognition of
the growing autonomy of adolescents’ and its interest in pro-
tecting adolescents from making decisions they may later
regret (18,19).
Conclusion
Evaluation of the informed consent process, with respect to
adolescent patients, remains complex, and determining
capacity in adolescents is particularly difficult (19), at least
partly because adolescence is a period of developing maturity,
values, cognition, and autonomy. There is a consensus in the
literature that adolescents aged 14 years and over have the
capacity to understand information relevant to medical deci-
sion making. However, there is debate about their ability to
appreciate information required to make an authoritative
choice and a voluntary and mature decision.
With adolescents, one challenge is to involve them in the
informed consent process to the extent possible and to secure
and maintain respect for both adolescents and caregivers. Cli-
nicians need to recognize that adolescents’ capacity to con-
sent or refuse medical treatment is evolving, and an
assessment of an adolescent’s capacity must be made on an
individual basis, with close regard to the specificities of the
patient’s situation. Finally, there are many unanswered ques-
tions regarding the capacity of adolescents with mental health
difficulties to consent. Empirical research is needed to better
understand the development of capacity in adolescents with
and without psychiatric problems. This paper explored ado-
lescents’ participation in the informed consent process, with
the goal of helping clinicians to better reflect on the relevant
ethical and empirical issues.
W Can J Psychiatry, Vol 50, No 9, August 2005

Funding and Support
We acknowledge the support of the Canadian Institutes of Health
Research (grant 64471). A portion of this paper was presented at
the Ontario Psychiatric Association conference, 2004 Jan; Toronto
(ON).
References
1. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. New York:
Oxford University Press; 2001.
2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to
ethical decisions in clinical medicine 3rd ed. New York: McGraw-Hill; 1992.
3. President’s Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research, Washington. Making health care
decisions: a report on the ethical and legal implications of informed consent in
the patient–practitioner relationship. Vol 1. Washington (DC): US Government
Printing Office; 1982.
4. Grisso T, Appelbaum PS. Assessing competence to consent to treatment. A guide
for physicians and other health professionals. New York: Oxford University
Press; 1998.
5. Glass KC. Refining definitions and devising instruments: two decades of
assessing mental competence. Int J Law Psychiatry 1977;20(1):5–33.
6. Pepper-Smith R, Harvey W, Silberfeld M. Competency and practical judgment.
Theor Med 1996;17:135–50.
7. Roth LH, Meisel A, Lidz CW. Tests of competency to consent to treatment. Am J
Psychiatry 1977;134:279– 84.
8. Harvey W. An ethical analysis of competence and its assessment [Unpublished
Monograph]. Toronto (ON); 1993.
9. Beauchamp TL. Competence. In: Gardell Cutter MA, Shelp EE, editors.
Competency: a study of informal competence determinations in primary care.
London: Kluwer Academic Publishers; 1991.
10. Substitute Decisions Act. Statutes of Ontario c.30. (1992).
11. Rozovsky LE. The Canadian law of consent to treatment. 3rd ed. Markham
(ON): Lexis Nexis Canada Inc; 2003.
12. Reibl v Hughes. 2 Supreme Court Reports 880 (S.Ct. Canada 1980).
13. Dickens BM. Informed consent. In: Downie J, Caulfield T, Flood C, editors.
Canadian Health Law and Policy, 2nd ed. Markham: Butterworths; 2002.
p 129–56.
14. Hopp v Lepp. 2 Supreme Court Reports 192 (S.Ct. Canada 1980).
15. Etchells E. Voluntariness. In: Singer P, editor. Bioethics at the bedside. Ottawa
(ON): CMAJ; 1999.
16. Malette v Shulman. 72 Ontario Reports (2d) 417 (Ontario Court of Appeal
1990).
17. Harrison C, Kenny NP, Sidarous M, Rowell, M. Bioethics for clinicians:
9. Involving children in medical decisions. CMAJ 1997;156:825–8.
18. Gilmour JM. Children, adolescents, and health care. In: Downie J, Caulfield T,
Flood C, editors. Canadian Health Law and Policy. 2nd ed. Markham (ON):
Butterworths; 2002. p 205–49.
19. Scott ES, Reppucci ND, Woolard JL. Evaluating adolescent decision making in
legal contexts. Law Human Behav 1995;19:221–44.
20. Furby L, Beyth-Marom R. Risk taking in adolescence: a decision-making
perspective. Dev Rev 1992;12:1–44.
21. Beyth-Marom R, Austin L, Fischhoff B, Palmgren C, Jacobs-Quadrel M.
Perceived consequences of risky behaviours: adults and adolescents. Dev
Psychol 1993;29:549–63.
22. Cohn LD, Macfarlane S, Yanez C, Imai WK. Risk-perception: differences
between adolescents and adults. Health Psychol 1995;14:217–22.
23. Steinberg L, Cauffman E. Maturity of judgment in adolescence: psychosocial
factors in adolescent decision making. Law Human Behav 1996;20:249–72.
24. Schachter D, Kleinman I. Psychiatrists’ attitudes about and informed consent
practices for antipsychotics and tardive dyskinesia. Psychiatr Serv
2004;55:714–7.
25. Munetz MR, Roth LH, Cornes CL. Tardive dyskinesia and informed consent:
myths and realities. Bull Am Acad Psychiatry Law 1982;10(2):77–88.
26. Kleinman I, Schachter D, Koritar E. Informed consent and tardive dyskinesia.
Am J Psychiatry 1989;146:902–4.
27. Schachter D, Kleinman I, Prendergast P, Remington G, Schertzer S. The effect
of psychopathology on the ability of schizophrenic patients to give informed
consent. J Nerv Ment Dis 1994;182:360–2.
28. Grisso T, Appelbaum PS. The MacArthur Treatment Competence Study. III.
Abilities of patients to consent to psychiatric and medical treatments. Law
Human Behav 1995;19:149–74.
29. Rudnick A. Depression and competence to refuse psychiatric treatment. J Med
Ethics 2002;28:151–5.
30. Culver CM, Gert B. The inadequacy of incompetence. Milbank Quarterly
1990;68:619–43.
Can J Psychiatry, Vol 50, No 9, August 2005 W
Informed Consent and Adolescents
31. King NMP, Cross AW. Children as decision makers: guidelines for
paediatricians. J Pediatr 1989;115(1):10–6.
32. Koocher GP, DeMaso DR. Children’s competence to consent to medical
procedures. Pediatrician 1990;17:68–73.
33. Leikin SL. Minors’ assent or dissent to medical treatment. J Pediatr
1983;102:169–76.
34. Hesson K, Bakal D, Dobson KS. Legal and ethical issues concerning children ’s
rights of consent. Can Psychol 1993;34:317–28.
35. Pearce J. Consent to treatment during childhood. The assessment of competence
and avoidance of conflict. Br J Psychiatry 1994;165:713–6.
36. Grisso T, Vierling L. Minors’ consent to treatment: a developmental perspective.
Prof Psychol 1978;9:412–27.
37. Weithorn LA, Campbell SB. The competency of children and adolescents to
make informed treatment decisions. Child Development 1982;53:1589–98.
38. Mulvey EP, Peeples FL. Are disturbed and normal adolescents equally
competent to make decisions about mental health treatments? Law Human Behav
1996;20:273–87.
39. Kaser-Boyd N, Adelman HS, Taylor L. Minors’ ability to identify risks and
benefits of therapy. Prof Psychol Res Pr 1985;16:411–7.
40. Casimir KC, Billick SB. Competency in adolescent inpatients. Bull Am Acad
Psychiatry Law 1994;22(1):19–29.
41. Billick SB, Burgert III W, Friberg G, Downer AV, Bruni-Solhkhah SM. A
clinical study of competency to consent to treatment in pediatrics. J Am Acad
Psychiatry Law 2001;29:298–302.
42. Bastiaens L. Knowledge, expectations, and attitudes of hospitalized children and
adolescents in psychopharmacological treatment. J Child Adoles
Psychopharmacol 1992;2:157–71.
43. Bastiaens L. The impact of an intensive educational program on knowledge,
attitudes, and side effects of psychotropic medications among adolescent
inpatients. J Child Adoles Psychopharmacol 1992;2:249–58.
44. Bastiaens L. Compliance with pharmacotherapy in adolescents: effects of
patients’ and parents’ knowledge and attitudes toward treatment. J Child Adoles
Psychopharmacol 1995;5(1):39–48.
45. Ambuel B, Rappaport J. Developmental trends in adolescents’ psychological and
legal competence to consent to abortion. Law Human Behav 1992;16:129–54.
46. Grisso T, Appelbaum PS. Mentally ill and non-mentally-ill patients’ abilities to
understand informed consent disclosures for medication: preliminary data. Law
Human Behav 1991;15:377–88.
47. National Work Group on Literacy and Health. Communicating with patients who
have limited literacy skills. J Fam Pract 1988;46:168–76.
48. Glascoe FP, Oberklaid F, Dworkin PH, Trimm F. Brief approaches to educating
patients and parents in primary care. Pediatrics 1998;101(6):E10.
49. Roberts LW. Informed consent and the capacity for voluntarism. Am J
Psychiatry 2002;159:705–12.
50. Scherer DG, Reppucci ND. Adolescents’ capacities to provide voluntary
informed consent. The effects of parental influence and medical dilemmas. Law
Human Behav 1988;12:123–40.
51. Scherer DG. The capacities of minors to exercise voluntariness in medical
treatment decisions. Law Human Behav 1991;15:431–49.
52. Etchells E, Sharpe G, Elliott C, Singer PA. Bioethics for clinicians: 3. Capacity.
CMAJ 1996,155:657–9.
53. Sneiderman B, Irvine JC, Osborne PH. Canadian medical law: an introduction
for physicians, nurses and other health care professionals. 3rd ed. Scarborough
(ON): Carswell; 2003.
54. C (JS) v Wren. 2 Western Weekly Reports 669. (Alberta Court of Appeal 1987).
55. Picard EI, Robertson GB. Legal liability of doctors and hospitals in Canada. 3rd
ed. Scarborough (ON): Carswell; 1996.
56. Health Care Consent Act. Statutes of Ontario, Chapter 2, Schedule A (1996).
57. Civil Code of Quebec, S.Q. 1991, c.64, ss.14, 16.
Manuscript received March 2004, revised, and accepted April 2005.
1
Psychiatrist, Child, Youth and Family Program, Centre for Addiction and
Mental Health, Toronto, Ontario; Assistant Professor, Department of
Psychiatry and Public Health Sciences, University of Toronto, Toronto,
Ontario.
2
Psychiatrist, Mount Sinai Hospital and Centre for Addiction and Mental
Health, Toronto, Ontario; Assistant Professor, Department of Psychiatry
and Family and Community Medicine, University of Toronto Joint Centre
for Bioethics, Toronto, Ontario.
3
Professor Emeritus, Department of Philosophy, Victoria University in the
University of Toronto, Joint Centre for Bioethics, Toronto, Ontario.
Address for correspondence: Dr D Schachter, 250 College Street, Toronto,
ON M5T 1R8
e-mail: Debbie_Schachter@camh.net
539
 The Canadian Journal of Psychiatry—Review Paper

Résumé : Le consentement éclairé et les adolescents

Objectif : Explorer la doctrine du consentement éclairé et le développement de la capacité des
adolescents souffrant de problèmes psychiatriques afin d’aider les cliniciens à mieux exprimer les
questions d’ordre éthique pertinentes.
Méthode : La documentation pertinente sera discutée. Le rôle de l’incapacité psychiatrique dans la
capacité de consentir des adolescents sera exploré.
Résultats : Dans la common law, il n’y a pas d’âge minimum auquel les personnes sont capables de
consentir à un traitement médical, et pas d’âge au-dessous duquel ils sont incapables de consentir. Le
droit des adolescents à l’autodétermination se fonde sur leur capacité de comprendre et de juger
l’information utile à la décision médicale, et sur leur capacité de consentir volontairement et
librement. La documentation reconnaît à l’unanimité que vers l’âge de 14 ans, les adolescents ont la
capacité cognitive de comprendre l’information nécessaire au consentement. Cependant, il y a des
données empiriques limitées en ce qui concerne la capacité des adolescents de juger l’information et
de prendre une décision volontaire.
Conclusion : Les cliniciens doivent faire participer les adolescents au processus du consentement
dans la mesure du possible et évaluer les éléments de la capacité de consentir au traitement au cas par
cas, reconnaissant que la capacité peut évoluer à mesure que mûrissent les aptitudes cognitives et les
valeurs des adolescents.

540
W Can J Psychiatry, Vol 50, No 9, August 2005

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