GROWING PAINS? AN OVERVIEW OF THE MATURE MINOR DOCTRINE AND ITS PATCHWORK CRITERIA FOR APPLICATION.

By Mallie Brocato

Introduction

The mature minor doctrine generally allows minors regarded sufficiently mature to consent to medical treatments without parental involvement. The doctrine plays a crucial role in balancing minor autonomy with the parental right to make medical decisions for their children.

This article examines the legal foundations of the doctrine and its application across the country. By analyzing the variations in state approaches, it provides a comprehensive survey of the doctrine’s application and explores whether a standardized federal framework is warranted.

    I.        The Legal Framework of the Mature Minor Doctrine

The mature minor doctrine is rooted in the common law principle of parens patriae, which allows the state to sue on behalf of its citizens. Moreover, it grants the state authority to protect the welfare of minors, even when it limits parental authority.[1] It is well established that parens patriae applies to medical decision-making cases;[2] for purposes of this article, the principle demonstrates that parental authority in children’s healthcare is not absolute and can be superseded under certain circumstances.

The applicability of parens patriae “fades as the child gains maturity, due to the child's ability to exercise informed consent.”[3]Thus comes the mature minor doctrine, which generally acknowledges that minors may be capable of making informed medical decisions without the help of their parents.[4]

A majority of states in the U.S. have recognized the mature minor doctrine either by common law or by statute. The different approaches, combined with a complete lack of this doctrine in some states, creates variation in the doctrine’s application across jurisdictions.

    II.        Varying Criteria for When the Doctrine Applies

The application of the mature minor doctrine varies considerably across jurisdictions, with no one, uniform set of criteria. However, there are three key factors that summarize determinations made under the doctrine: age, maturity, and type of medical treatment. At least one of these factors is found in each state version of the doctrine.

        A.        Age

Age is often a primary consideration, with some states setting specific thresholds above which a minor may be presumed mature enough to consent to certain medical treatments.

For example, in Alabama, minors 14 years or older can consent to their own medical treatment: “Any minor who is 14 years of age or older . . . may give effective consent to any legally authorized medical, dental, health or mental health services for himself or herself, and the consent of no other person shall be necessary.”[5] Alabama’s statute is significant because if a minor is at least 14 years old (or meets any of the other specified conditions), he or she only needs to meet that one requirement to be able to consent to their own treatment. 

The same cannot be said for other state statutes. Colorado also has a statutory mature minor doctrine; its age threshold is 15 years or older. However, meeting this age requirement is just one of several conditions to be satisfied before the minor can consent to his or her own treatment.[6]

Overall, while some states provide clear statutory guidance on age thresholds, others incorporate additional criteria to evaluate whether a minor possesses the necessary understanding and reasoning to make informed medical decisions. States justify this because age alone is rarely the sole determinant of maturity.

        B.        Maturity

Some interpretations to the mature minor doctrine hinge on a minor’s maturity.[7] Statutes often recognize certain adult-like experiences or responsibilities as indicators of maturity and deem minors who have navigated them capable of consenting to their own medical care. 

Take Alaska’s mature minor doctrine illustrates this approach for example: a minor can consent to their own medical services where that minor (1) lives separate from the parent(s); (2) manages their own finances; (3) is pregnant; or (4) seeks treatment for venereal disease.[8]

These criteria reflect the law’s recognition that certain life circumstances push minors into roles of independence typically associated with adulthood. Living apart from parents and managing one's own finances demonstrate self-

sufficiency and decision-making skills, while pregnancy and seeking treatment for venereal diseases involve deeply personal and consequential healthcare decisions.

Additionally, maturity can also be determined through a case-by-case evaluation of the minor; this typically involves a comprehensive assessment of several factors, with no one factor being dispositive.[9] Commonly considered factors include the minor’s academic performance in school, their understanding of death, any personal experience with serious illness, awareness of the decision-making process, the decision's impact on family and others, history of major medical or nonmedical decisions, and the clarity and strength of the child's intent.[10]

Ultimately, each factor reinforces the idea that minors in these situations must have the autonomy–akin to that of legal adults–to act in their own best interests. By tying medical consent to these experiences, the law acknowledges that maturity can be shaped by real-world responsibilities and hardships.

        C.        Type of Medical Treatment

The nature and complexity of the medical treatment also influences the application of the mature minor doctrine. More invasive or high-risk treatments likely require a greater level of maturity and understanding—even for adults.

A critical element in applying the mature minor doctrine is the minor's comprehension of the treatment; it is essential that the minor understands the nature, risks, benefits, and potential side effects of the treatment. State doctrines use language that reflects this; in Arkansas, only minors who sufficiently “understand and appreciate the consequences of the proposed surgical or medical treatment or procedures” can consent,[11]and in Idaho, anyone “who comprehends the need for, the nature of, and the significant risks” of the treatment can “consent thereto on his or her own behalf.”[12]

The majority of states have enacted legislation that restricts minors' ability to consent to abortion without parental involvement (either notification or consent); however, the Supreme Court requires a bypass to parental involvement for mature minors or where the abortion is in the best interests of the minor.[13]While not discussed here, these legislative actions reflect ongoing debates and controversies surrounding the extent of the mature minor doctrine.

    III.        A Survey of State Mature Minor Doctrines

As of today, thirty-eight states plus the District of Columbia recognize the mature minor doctrine.[14] As previously mentioned, such doctrines come in two forms: statutory and common law.

The overwhelming majority of states have codified this doctrine in respective state statutes.[15] However, as evidenced above, the statutes vary in their requirements. 

In other states, the mature minor doctrine has been primarily recognized and developed through judicial decisions. Courts in these states have established legal precedents based on common law principles and case-specific analyses. Only three states which have foregone codification preserved this doctrine in the common law: Michigan, Tennessee, and West Virginia[16].

Judge-made mature minor doctrines operate similarly to statutory ones. For example, Belcher v. Charleston Area Med. Ctr., the landmark case that established West Virginia’s mature minor doctrine, relies on all three criteria for application–the minor’s age, maturity, and the type of medical treatment involved:

Whether a child is a mature minor is a question of fact. Whether the child has the capacity to consent depends upon the age, ability, experience, education, training, and degree of maturity or judgment obtained by the child, as well as upon the conduct and demeanor of the child at the time of the procedure or treatment. The factual determination would also involve whether the minor has the capacity to appreciate the nature, risks, and consequences of the medical procedure to be performed, or the treatment to be administered or withheld.[17]

The remaining twelve states[18] do not recognize a generally applicable mature minor doctrine. However, that is not necessarily for a lack of trying. For example, in Connecticut, the Court addressed the issue of whether to adopt the mature minor doctrine in In re Cassandra C.[19] While the court did say that “[f]or purposes of the mature minor doctrine, a mature minor is a minor who is competent to make medical decisions,”[20] it ultimately decided not to adopt the doctrine in this case.[21]

    IV.        A Federal Framework is Only Good in Theory

It is obvious that the application of the doctrine varies across different states. Moreover, the sensitive nature of the doctrine raises complex ethical questions, including determining the appropriate age and maturity thresholds for different types of medical treatments. Would a consistent, nationwide framework help?

Currently, the only federal guidance on the doctrine exists in the contexts of contraception and abortion, with federal requirements for allowing some minors to access to contraception, and federal allowance for states to require parental involvement for abortion, with required exceptions for maturity and best interests.[22] Regarding a general application of the doctrine, a federalized doctrine would ensure consistency across states, thus eliminating current disparities stemming from geography and a minor’s ability to cross state lines. While such a framework is likely within Congress’s authority under the Commerce Clause—especially given the recognition that the federal government can set national standards for healthcare[23]––it presents significant practical challenges. Medical licensing is regulated at the state level, meaning physicians are subject to different training, licensing requirements, and professional standards depending on their jurisdiction.[24] Some versions of the doctrine require the physician to assess whether a minor possesses the maturity to make medical decisions independently.[25] Because this determination relies on a physician’s professional judgment—shaped by state-specific regulations and standards—a federal doctrine would likely face significant implementation difficulties. Thus, despite being constitutionally permissible, nationwide uniformity would likely be difficult to achieve in practice.

Given these challenges, the future of the mature minor doctrine will likely remain a matter of state-by-state regulation rather than a unified federal standard.

Conclusion

Overall, the mature minor doctrine remains a dynamic and evolving legal principle. As medical advancements continue and societal views on adolescent autonomy evolve, the legal landscape surrounding this doctrine will likely continue to shift.

[1] See Prince v. Massachusetts, 321 U.S. 158, 167 (1944) (“[T]he state has a wide range of power for limiting parental freedom and authority in things affecting the child's welfare . . .”).

[2] See, e.g., Missouri v. Illinois, 180 U.S. 208, 241 (1901) ([I]f the health and comfort of the inhabitants of a State are threatened, the State is the proper party to represent and defend them.).

[3] Jennifer L. Rosato, The Ultimate Test of Autonomy: Should Minors Have A Right to Make Decisions Regarding Life-Sustaining Treatment?, 49 Rutgers L. Rev. 1, 69 (1996) (citing In re E.G., 549 N.E.2d 322, 326-28 (Ill. 1989) (“The parens patriae power fades, however, as the minor gets older and disappears upon her reaching adulthood.”)).

[4] See 67 A.L.R. 4th 511 § 7 (“[C]ourts . . . considering the "mature minor" exception to the general rule requiring parental consent, [have] held that the minors treated by medical practitioners were of sufficient age or maturity to give their own consent to treatment, making the consent of their parents unnecessary.”).

[5] Ala. Code § 22-8-4 (emphasis added). Age is only one “category” of minors who may generally consent to their own treatment; the others are high school graduates, married or divorced minors, and pregnant minors. See id.

minors into roles of independence typically associated with adulthood. Living apart from parents and managing one's own finances demonstrate self-sufficiency and decision-making skills, while

[6] If a minor under the age of majority (18 in Colorado) wants to consent to their own treatment, he or she must (1) be fifteen years of age or older; (2) not be living with their parent(s); and (3) manage their own finances. See Colo. Rev. Stat. § 13-22-103(1).

[7] See D.C. Mun. Regs. tit. 22-B, § 600.10(b)(2) (establishing informed consent where “the minor is able to comprehend the need for, the nature of, and any significant risks ordinarily inherent in the health services to be provided.”).

[8] See Alaska Stat. § 25.20.025(a). The term “venereal disease” is interchangeable with “sexually transmitted disease” and “sexually transmitted infection.” See Editorial Note to Sexually Transmitted Infections, Nat’l Inst. of Allergy & Infectious Diseases (Apr. 12, 2024), https://www.niaid.nih.gov/diseases-conditions/sexually-transmitted-infections.

[9] Rosato, supra n. 3, at 66.

[10] See id. at 65.

[11] Ark. Code Ann. § 20-9-602(7).

[12] Idaho Code § 39-4503.

[13] See, e.g., Ariz. Rev. Stat. Ann. § 36-2152 (limiting abortions on unemancipated minors to those only consented to by the parent or by the court).

[14] This number does not include state laws that are treatment-specific (e.g., only applies to minors consenting to treatment for abortions).

[15] The following thirty-six states have enacted a statutory mature minor doctrine: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, District Of Columbia, Florida, Hawaii, Idaho, Illinois, Indiana, Kansas, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Missouri, Montana, Nevada, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Virginia, Washington, and Wyoming.

[16] See generally Family Indep. Agency v. AMB (In re AMB), 640 N.W.2d 262 (2001) (recognizing the mature minor doctrine in Michigan); Cardwell v. Bechtol, 724 S.W.2d 739 (Tenn. 1987) (recognizing the mature minor doctrine in Tennessee); Belcher v. Charleston Area Med. Ctr., 422 S.E.2d 827 (1992) (recognizing the mature minor doctrine in West Virginia).

[17] Belcher, 422 S.E.2d at 838.

[18] Those states are Connecticut, Georgia, Iowa, Kentucky, Mississippi, Nebraska, New Hampshire, New Jersey, Ohio, South Dakota, Vermont, and Wisconsin.

[19] See generally 316 Conn. 476, 112 A.3d 158 (2015).

[20] Id. at 171.

[21] See id. at 172-73 ([T]here is no need for [the court] to reach the question of whether we should adopt the mature minor doctrine because, even if [it] were inclined to do so, the doctrine would not apply.”).

[22] See Bellotti v. Baird, 443 U.S. 622, 643 (1979) (explaining that mature minors can seek an abortion without parental consent if they can demonstrate maturity to a court).

[23] See Gonzales v. Oregon, 546 U.S. 243, 271 (2006).

[24] See, e.g., Ala. Code § 34-24-70.

[25] See Haw. Rev. Stat. Ann. § 577D-2(a) (“. . . may provide primary medical care and services to a minor who consents to the primary medical care and services if the physician reasonably believes that . . .”.