In pediatrics, consent actually amounts to authorization by the parents for treatments and procedures, reflecting the assumption that parents are the most authentic spokespeople for their children. However, most children are capable of consent after age 14, by which time, with normal development, they possess full decisional capacity and flexible thinking (Brock, 1989). “Assent” refers to a child’s agreement with the proposed treatment. Although it is not a term defined in law, assent respects children as individuals with developing capacities for participation in health care decisionmaking. Conversely, “coercion” describes an essentially paternalistic act of forcing participation in treatment or research, which should be avoided.
Assent in pediatric practice consists of four basic elements:
demonstrating respect for the child as a patient and as a developing person by assisting the child to develop an appropriate awareness of illness;
disclosing the nature of the proposed intervention and what the child is likely to experience (truth telling);
assessing the child’s understanding of information and the factors influencing his or her evaluation; and
demonstrating respect for emerging autonomy and the development of decisionmaking capacity by soliciting expressions of willingness on the part of the child to accept the intervention (Bartholome, 1993).
The American Academy of Pediatrics Committee on Bioethics recommends that assent for treatment should be obtained from the pediatric patient when developmentally appropriate and should be binding when used in the research setting (AAP, 1995). However, guidelines from the National Institutes of Health (NIH) Office for Protection from Research Risks (OPRR) state that assent or dissent is conditional on parental permission if participation in research is potentially beneficial to the child, in which case parental permission overrides the child’s dissent (OPRR, 1991).
Legal and ethical debates about the appropriate age of consent for medical treatment or research participation are interesting and important but oversimplify the issues when it comes to caring for adolescent patients. In the first place, decisionmaking capacity itself is not a static phenomenon; it can be intermittent or fluctuating, and it may vary over time with changes in clinical condition. Secondly, people are not static either: like adults, adolescent patients vary significantly in their ability to comprehend what is happening to them. Care providers, therefore, need to be attentive to changing competence in adolescent patients (Friebert and Kodish, 1999).