It is obvious that 13-year-old José does not want to be in your office, much less consider comprehensive orthodontic therapy. He is an only child—and very bright—who obviously rules the house. His doting mother appears to be more like his servant than his parent. Although you attempt to connect with him by discussing a local baseball star’s recent grand-slam home run, he wants nothing to do with you, despite your most valiant efforts. Even getting him to open his mouth takes diplomatic negotiation, and his mom seems powerless in motivating him to cooperate. He has a severe malocclusion with poor oral hygiene. After you determine that he would significantly benefit from fixed appliance therapy, you ask him why he is so staunchly opposed to the benefits of orthodontic treatment. “I just don’t want it. My teeth don’t matter to me,” he responds abruptly. His mother immediately becomes agitated. “José, you need braces. Your teeth look terrible.” José responds with a dramatic cross of his arms, locked in a gesture of defiance.
Despite José’s age of minority, does his opinion qualify him to reject orthodontic therapy in contradiction to his mother’s wishes?
A patient’s competence to choose treatment is hallmarked by his general understanding of the therapy, acceptance of the risks, and appreciation of the benefits of treatment. A person who cannot process this information may not be suitable for making the autonomous decision to accept or decline therapy. Yet, those who have these abilities can participate in the decision-making process, often regardless of age. This ability has been called an understanding of the “consequence of one’s actions.” Some ethicists believe that although parents maintain authority to decide what is best for their children, their authority is not absolute. Adolescents often have the right and ability to become informed of the consequences of accepting or rejecting treatment if they mentally qualify for such a process. This is seen as another facet of autonomy or “self-determination.”
The difference between parental informed consent, parental permission , and patient assent is pertinent in a discussion of adolescent autonomy. Although only patients can give informed consent, parents provide informed permission for diagnostic or therapeutic procedures involving their children. The American Association of Pediatrics assigns the term “patient assent” to a minor’s acceptance of a procedure. The process of assent is patterned after the process of obtaining informed consent in the adult. Assent also acknowledges the child’s ability to sufficiently comprehend the treatment to enable him to proceed with or decline therapy.
Obtaining assent from a minor is also intended to elevate the patient’s engagement and motivation in therapy. This is critical in orthodontic treatment. Orthodontists are typically proficient in obtaining patient assent, as we have generally attempted to involve our patients in therapy given our dependence on their cooperation.
Many factors might exceed or impact an adolescent’s comprehension level, such as emotional prejudice or the inability to discern relevant from irrelevant information. Those patients who are averse to a specific treatment plan may require treatment plan modification to accommodate their objections. Others may commence therapy with resentment but later evolve into fine cooperators once they perceive our sincerity and dedication toward helping them. Yet, many attentive adolescents have the immediate ability to play a role in their treatment decision.
You feel inadequate in your failure to engage young José in the beneficial aspects of orthodontic correction. It is obvious that he will not give his assent. The question in your mind is whether to concede to his mother’s advocacy for orthodontic therapy or to accept his decline of treatment, even though he is a minor. If an alternative form of therapy remains unacceptable to him, you might suggest that he refrain from treatment for the time being. If you truly believe in adolescent autonomy, José stands as the ruler of himself.