62 [80 O p. Att’y

1 This opinion is not intendedt o address issues of consent for treatme nt of minors in any other institu tional set tings. CORRECTI ONS

H EAL TH

) A UTHORITY TO C ONSENT TO M EDICAL T REATME N T F OR M INORS I N A DULT C ONFINEMENT F ACILI TIES

January 25, 1995

Honorab le James W. Hubbard House of Delegates You have request ed our opini on whether curr entlaw requir es State and lo cal ad ult dete ntion a nd co rrectio nal fa cilities housing inmates under 18 years of age who are chargedas adult s or ser ving sentence s as adul ts t o obtain t he cons ent of p arents or guardi ans of thes e pr ison ers p rior to pro vid ing m edic al ca re. For the reasons stated below, we conclude as follows: As a general rule, the physi cian who is t reating a mino r h eld in a n adu lt detent ion or co rrection al fac ility 1 should obt ain the consent of the mino r’s parent or

guardian f

or medical t

reatment t

hat goes beyond a routi ne response to common ailments. Under some circum stances, how ever, a physici an may provide mor e signi ficant forms of medical treat ment to a pri soner who is a minor without t

he consent of

the minor’s par ent or guardian:
1. Treatmentthat i s necessary to r espond to a m e dical emergency may be provided ei ther wit h the consent

of the minor

or wit hou t con sen t. 2. If the minor i s married

or the par ent of a c hild, any form of tre atm ent m ay b e pr ovi ded wit h th e co nse nt o f the m ino r. 3. Treatmentmay also be provi ded for any of the condi tions identi fiedin §§20-102( c) and 20-104( a) of t he Health- General (“H G” ) A rticle , M ary land Co de, w ith th e co nse nt o f the m ino r.Gen. 62] 63

2 The Division carries out this responsibility by means of a contract with a provider of

health c are ser

vices. 4. Fi nal ly, although t

he matter i s not set

tled in Maryland, t

he atte nd ing phys ician may rely on the informed consent of a minor who is reasona

bly deemed to be matur e enough to provi de consent for a par ticul ar tre atm ent.

I

Duty to Pro vide Nee ded MedicalTreatment The custodi an of a pri soner has a legalduty to s afegua rd the health of a p r isoner . In par t, t his l egal duty flows fr om the United States Co nstitu tion

. Se e Es te ll e v . G amb le , 429 U.S. 97 (1976) (Eigh th Amendm ent requires state to p rovid e ade quate med ical care to prisone rs wh ere failu re to do so w ould am oun t to delib erate indif ference to serio us m edica l need s); Buffi ngton v. Baltimor e Co unty , 913 F.2d 113 (4th Cir. 1990) (due proces s claus e guarant ees a pre-trial detainee at least the sam e right to me dical care). In part, the duty is statutor y. A pris oner in the cust ody of the Divi sion of Correcti ons is entitled to “ade quate treatm ent” fo r an illne ss. Ar ticle 27 , §698. 2 A pre-trial detainee in the custody of a sh eriff o r com parab le jailor has a

right to nec essary me dical trea tme nt. Ar ticle 87, §§4 6 an d 48 of th e C ode

. See gene ral ly 58 Opinions of the AttorneyGeneral647 (19 73)

. How ever, these s tatut es do not addr ess the issue of inf ormed consentfort re atme nt. In ge neral, th e fact th at a pe rson is imprisoned

does not deprive the p risone r of hi s or her “ right to be free from unjust ifi ed intr usions into the body,

... the rela ted righ t to refuse unw anted me dical trea tme nt,

... and .. . the right to suff icie nt info rma tio n to int elli gently e xercis e those rights .” White v. Napoleon, 897 F.2 d 10 3, 11 1 (3 d C ir. 19 90)

. See Washington v. Harper , 494 U.S . 210 , 221-22 (1990). T o be sure, the S tate’s interest in eff ecti ve pris on administ

rati on entitles i t to adm iniste r so me types of

treatmen t witho ut the c onse nt

)indeed, over the object ion

)of a priso ner
. See g ener ally Washington v. Harper , 494 U.S. at 22 7. See a lso, e.g., In r e Ca ulk , 480 A.2d 93 (N .H. 1984) (alt hough prisone r has ri ght under s tate consti tuti on to prevent unwanted infr ingement of bod ily integ rity, state inter est i n effective prisonadm inistration justifies fo rced fe eding of priso ner w ho w ould64 [80 O p. Att’y
otherw ise starv e to death). But cases of this k ind are exce ptions to the general rule t

hat the doctrine of inf

ormed consentapplie s with in jails a nd p rison s, jus t as it d oes else wh ere. Hence, we turn to general principles of law governing c onsent for m edic al tre atm ent o f m ino rs. II Consent for Treatment of Minors
Be caus e minors are us ually t hought to be incapable of adeq uately assess ing allof the per tinent factor s invol ved in making important

medical decisions, the t ra di t i on alco mmonl aw r ul e d ee ms mino rs incapabl e o f c onse nting to me dical o r surgic al treatm ent. See, e.g. , Bonner v. Moran, 126 F.2d 121 (D.C . Cir. 19 41); In re Hudson , 126 P .2d 765 (W ash. 1942 ). “[D]uri ng the for mative years of childhood and adolesce nce, mino rs o ften l ack the experience, perspective, and ju dgm ent to re cogn ize an d avo id cho ices tha t could be detri mental to t

hem.” Bellotti v. Baird , 443 U. S. 622, 635 (1979). Parents, a s natu ral guardians, have long poss essed common law autho rity to make medical deci sions f or their chil dren without being appointe d b y a cou rt

. See generall y Parham v. J. R. , 442 U.S. 584 (1979). Parentalautho rity und er the c om mo n law has b een c odified in §5-203 of t he Fam ily Law (“FL”) Art icle , Maryland Code, whic h deline ates t he responsibili ties of a parent in rel ation to the chi ld. This secti on provides that “ parents are the joint naturalguardians of their minor chil d” and “the parents of a m inor child are jointly and se v erally responsible fo r the child’s supp ort, care, nurture, welfare and edu catio n.” See Middleton v . Middlet on , 329 Md. 627, 633, 620 A.2d 1363 (1993). While this secti on does not exp ressl y i nclude medical care w ithin the responsibilities of a pare nt, the Court of Ap peals has held t

hat medical car e is i ndeed embraced withi n the scope of the br oad language us ed in F L § 5-2 03. State v . Fab ritz , 276 M d. 41 6, 3 4 8 A .2d 2 74 ( 197 5), cert. denied , 425 U.S. 942 (1976). See also Crai

g v. State , 220 M d. 590, 155 A.2d 6 84 (195 9); Robey v. State , 54 Md. App. 60, 456 A.2d 953, cert. denied , 296 Md. 224 (19 83)

. Physici ans general ly must ob tain the co nsen t of the p arents before perfor

ming any medical treatment on a c hild. “When the patie nt is a m ino r, the patie nt is le gally belo w th e ‘ag e of con sen t,’Gen. 62] 65
and the gener al rul e is t hat a medicalpractitioner will be l iable for treating a mino r without the c onsent of the mino r’s par ents .” Danny R. Ve il leu x, A nno tatio n, Medical Practi tioner ’s Liabi lit y for Tr eatment

Give n C hild W ithout P aren t’s Co nsen t, 67 A .L.R

. 4t h 511, 517 (19 89)

. See also Ruth R. Faden & Tom L. B eau cha m p, A History and Theo ry of I nfor med Consent36 (1986). If a child i s a ward of the court, these r esponsibi lities devolve upon the guardian. See W entz el v. M ontgom ery Ge n. H osp . Inc ., 293 Md. 685, 701-02, 447 A.2 d 12 44 ( 198 2).
In order t o make medical treatment de cisi ons for their chi ldren, paren ts are ent itl ed to the same informati on regardi ng the ri sks and bene fits of proposed t

reatmentas w ould be pr ovid ed to the m inor if the minor w ere competent to make the treatment de cisi on personal ly. See Marino v. Ballestas , 749 F.2d 162 ( 3d Cir . 198 4). See g ener ally Sardv. Hardy , 281 Md. 432, 439, 379 A.2 d 10 14 ( 197 7). Hence, as a general matter, a physici an seeking to treat a minor in cust od y must obtain t

he infor med consent of t

he minor’s par ent or guardian prior to provi ding medicaltreatm ent to th e m inor. T his gene ral rule has important

excepti ons, however, that we di scuss i n the balance of this o pin ion

.

III

Consent by Minorto Treat ment A. Statu tory A utho rity
HG §20-102 (a) gr an t s t o a n e man cipa t edmi no r “ t he same capa city as an adul t to c ons en t to me di ca l t re atmen t .

.. .” An emancipatedmino r is one w ho is m arried or t he parentof a chil d. HG §20 -102 (a). A n em ancip ated m inor is also autho rized b y statute to execute an a dvance dir ecti ve under the Health Care Deci sion s Ac t. See HG §5- 601 (b).
In add ition , a m ino r, e ve n i f n ot emanc i pa t ed , “h as t he same capaci ty as an adult

to consent

to medicaltreat

ment if, in the judgment of t

he att ending physi cian, the li fe or health of t he minor wo uld be affec ted adver sely by del aying trea tment to obt ain the consentof another

ind ivid ual.” HG §20-102(b). Thus, a physici an treating a mi no r p ri so ne r may act on the m inor’s c onse nt to emergency treat

men t w ithout

obtaining the consent

of a parent

or66 [80 O p. Att’y guardian. See also Part I V below (emergency treatment wi thout consen t).
HG §20-102(c) identi fies seven circumstances under which a minor “has the sam e cap acit y as an adult to consent ” to medical treatm ent: (1) Treatmentforor advice about drug abus e;

(2) Treatmentfor or a dv i ce ab ou t al co ho l i sm; (3) Treatmentfor or a dvice about venereal diseas e; (4) Treatmentfor or a dvice about pregnancy; (5) Treatment for or a dvice abou t contrac eption ot

her than s teri lization; (6) Physicalexam ination and tre atm ent o f injur ies for an al leged ra pe or sexual offense ; and (7) Physicalexam inatio n to obtain evidence of an all eged rape or

sexual of

fense. Finally, HG §20-10 4(a) authori zes minors who are 16 ye ars ol d or ol der “t o conse nt to consultation, diag nosis, and treatm ent of a m enta l or e m otio nal d isord er b y a p hys ician or a clini c.”
B. Mature M inors Although the issue has n ot been re sol ved by the Maryland courts, a develop ing bod y of case law from o ther j u risdi ctions and scho larly comment suggest that a minor who can d emo nstrate that he or she is mature e nough to understan d the con sequen ces of a medical pr oc edur e may g ive th e req uisite info rm ed c ons ent. See genera ll y Restate ment (Second) of Torts §892A (1979) ( if per son consenting is a chi ld, t

he consent may st illbe effect ive if the ch ild is capable of

appreci ating nature, extent , and probabl e consequences of con duc t con sen ted to ); W . Pag e K eeto n, et a l., Prosser and Keeton on th e La w o

f T or ts §18, at

115 (5th ed. 1984) (capac ity of minor to consent

exist s when the minor has t he ability of an ave rage person t o underst and and we igh the bene fits of tr eatment); RhondaGen. 62] 67 Cohn, Minor’s Right

to Cons ent t o Med ical Care , 31 Med. Trial Technique Q. 286, 290-91 (1985) (minor may consent “ if t he minor is mature enough to unde rstand the nat ure and conseque n ce s of a medical procedu re that is for the min or’s bene fit and can weigh alternatives to the proc edure”). The Ill inois Supreme Court, f or example, hel d that

“a m ino r ... who was just months shy of her e ightee nth bir thday . .. and ... [who] the record i ndicat es was mature for her age” was l egall y authori zed to con sen t to m edic al tre atm ent. In re E. G. , 549 N.E.2d 32 2, 325 (Ill. 198 9). Th e Illinois c ourt o bserv ed tha t the ag e of m ajority “ is not an impenetra

ble barrier t

hat magical ly precludes a minor from possessing and e xercis ing ce rtain righ ts norm ally ass ociate d w ith adu ltho od.” Id

. A ccording to the court , “mature minor s may possess and e xercis e rights regard ing m edica l care th at are ro oted in this State’ s common law.” 549 N.E.2d at 326

. See also, e.g. , You nts v. St. Franc is Hosp. and Sc hool of Nursing, Inc. , 469 P.2d 330 ( Kan. 1970) (17 y ear old able to cons ent t o m in or surg ery); Cardwell v. Bechtel , 724 S.W.2d 739 (Ten n. 198 7) (17 year o ld able to consent to sp inal m anipu lation); Belcher v. Charleston Area Medical Center , 422 S.E.2d 827 (W.Va. 1992) (remand to t rialcourt t o d et ermine whether17 y ear old wa s able to cons ent t o “do not res uscit ate” order). The W est V irgin ia court obser ved that the is sue of “[w ]hethe r a child is a m ature m inor is a ques tion of fact”:

Whether the child h as the c apac ity to consent depends upon th e age, ability, experi enc e, educati on, training and de gre e of maturi ty of judgment obtain ed by the chi ld, a s well as upon the conduct anddemeanor of the c hild at the time of t

he procedure or

treat ment

... [and] whetherthe m inor h as the c apac ity to appr eciate the nature, risks , and conseque nces of the medicalprocedure to be perfo rmed, or the treat ment to be adminis tered or withheld.
422 S.E .2d a t 83 8. See also Ca rdw ellv. Bec htol, 724 S.W.2d at 745.68 [80 O p. Att’y

3 The fact that a minor is prosecuted as an adu lt does not

by itself establish that the minor may make all medical decisions, as if he or she w erean adult. Factors other than those related to the minor’s judgmen t and maturity

)the nature of the c rime, for example

)might determine whether the minor is prosecuted as an adult. See§§3-804(e) and 3-817(d) of the Courts and Judicial Proceedings Article, Maryland Code. Because we cons ider the se de cisions to be soundly r easoned, we think i t more li kely than not that Maryl and courts would accept the “ma ture m ino r” d octr ine in an a ppr opr iate c ase . A minor who has been held acc ountable as an adult for cr iminal misc o nduct , for example, would surel y be mature enough t o underst and and consent to, by ac ceptin g, the ro utine c are tha t is an im plicit p a rt of inst itutional conf

inem ent. 3 As a

pr ac t i ca l ma tter, no real i ssue of consentaris es when the tr eatment consi sts of lit tle more t

han the pro vis ion of over- the-count er medicat ion. A heal th care provider need not be concerned about consent t o dispense Tylenol t o a minor prisone r who complains of a head ache or to apply antis eptic and a ban dag e to a sm all cu t. Nevertheless, in the a

bsence of Maryland authority, we suggest that health care p rovid ers in th e priso n sett ing ac t caut iousl y for mo re se ri ou s f

orms of tre atm ent. If the treatment in ques tion i s one forwhich express , speci fic informed consent is ordinarily requir ed, the atte nding phy sician s hou ld first see k to o btain parenta l consent unless the m inor m ay co nsen t u nder circumst ances speci fied by sta tute. For these interv entions, reliance on the “m ature m inor” doctrine shou ld be a last reso rt, and o nly the n if t he physici an determines the minor to be mature e nough to provi de infor med con sen t for th e pa rticu lar p roc edu re in que stion

.

IV Treatment Wit hout Consen t Maryland law codifi es the l ong-accept ed principle that health care provider s may treat a pati ent in an em ergen cy w ithout c onse nt. HG §5-607 provides as follows:

A healt h care provi der may treat a patie nt who is i ncapable of

making an infor

med decision, w ithout consen t, if:Gen. 62] 69 (1) The treatment is o f an emergency medical nat

ure; (2) A person who is aut horized to give the consent

is not avail able i mm ediat ely; and (3) The atte nding physi cian det ermines that: (i) There is a sub stanti al risk of death or immediate or seri ous harm to the patie nt; and (ii) W ith a reasonabl e degree of medical certain t y, the lif e or heal th of t

he patie nt would affect ed adversely by del ayin g treatm ent to o btain c onse nt. This provisi on applie s as much in det ention or correctional f

acil iti es as e lsew her e. V Conclusion
In sum ma ry, it is our o pinion th at, as a genera l rul e, the physici an treating an impri soned minor shoul d obtain t he consent of the min or’s pa rent or guar dian fo r me dic al tre atment that goes beyond a r ou t i ne re sp on se t o c ommo n a i l men t s. Und er so me circumstances, how eve r, a physician m ay prov ide mo re signi ficant fo rms of medical t

reatment to a pris oner who is a minor wit hout the cons ent of th e m inor’s p arent o r gua rdian:
1. Treatmentthat i s necessary to r espond to a m edical emergency may be provided ei ther wit h the consent

of the minor

or wit hou t con sen t. 2. If the minor i s married or the parent of a ch ild, any form of tre atm ent m ay b e pr ovi ded wit h th e co nse nt o f the m ino r. 3. Treatmentmay also be provi ded for any of the condi tions identi fiedin HG §§20-102(c) and20-104(a) with the c onsent of the m ino r.70 [80 O p. Att’y
4. Fi nal ly, although t

he matter i s not set

tled in Maryland, t

he atte nd ing phys ician may rely on the informed consent of a minor who is reasona

bly deemed to be matur e enough to provi de consent for a p articular treatm ent. J. Joseph C urran, Jr. AttorneyGeneral Jack Sch wa rtz Chief Counsel Opinions & Advice