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Cynthia is a 15-year-old girl who has now been hospitalized for three weeks. She presented to the hospital with bleeding per rectum for two days. In the previous weeks, she had crampy abdominal pain post-prandially. She has lost about 15 pounds.

She was admitted to the GI Service, who diagnosed fulminant ulcerative colitis. She has been started on high-dose steroids to which immunosuppressants were added, without much change in the bleeding. Over the last three weeks, Cynthia has received three transfusions of blood and her hemoglobin is now 65. The pediatricians have ordered another 15 cc/kg. The GI consultants have consulted you for a subtotal colectomy and ileostomy. Cynthia was quite shocked by what she heard and after sobbing uncontrollably for 1 hour, has decided quite adamantly that she will not have the surgery.

Talking to Cynthia, you learn that she is quite an active girl. She swims competitively at the national level and was an alternate for the Olympic team for the games in Athens. Her specialty is the 100 meter backstroke. She also does the backstroke for the 400 medley. Cynthia was training 4 hours a day everyday except Sunday until she was hospitalized.

Cynthia also does some modeling. She has mostly worked at the local level, but she won a contest last September, which gave her a photo shoot with a teen magazine. Since then she has had a few calls from bigger modeling agencies trying to recruit her. The modeling career was put on the back burner with the preparations for the Olympics.

Cynthia is quite upset with her appearance. The steroids have made her gain some weight and she has started to get acne. She says she doesn’t recognize herself in the mirror. Her mother says that she noticed over the last few days that Cynthia is no longer interested in grooming herself.

You spend a long time discussing the indications and the surgery itself, including future J-Pouch and the possible complications. After all the discussion, Cynthia still refuses surgery. The parents agree that surgery is what should be done.

Questions to consider:

  1. Who should decide whether Cynthia will undergo the surgery or not? What is the definition of the mature minor in your state/province?
  2. What factors should be considered in the decision making and how should these factors be weighed – e.g. Cynthia’s age, maturity, understanding of the procedure and its consequences, etc.?
  3. Should you delay surgery in an attempt
    1. to allow Cynthia some measure of autonomy?.
    2. explore more fully the reasons for Cynthia’s refusal?
    3. to allow time for appropriate counseling?
  4. How could you assess Cynthia’s capacity? Given concerns regarding the effects of steroids and signs of depression, is Cynthia able to make an informed choice?
  5. Should our criteria for competency be more or less stringent depending on the type of case?
  6. Is there any reason not to respect the minor’s wishes?

Workshop 2

Topic: The mature minor

Curricular objectives

  1. To know the concept of mature minor, their rights and confidentiality issues
  2. To know the meaning of competence and how to assess for it
  3. To know the principle of assent

Ethical messages:

  • Chronological age is not a criteria for maturity
  • The autonomy of the mature minor should be respected

Pre-workshop readings:

  1. Kenny NP.  Whose choice?: deciding about therapeutic intervention in children.  In the good paediatrician: an ethic curriculum for use in Canadian pediatric residency programs, Toronto: Pediatrics Ethics Network via Department of Bioethics, The Hospital for Sick Children, 1996, Sec 3; pp133-142
  2. Sigman GS, O’Connor C.  Exploration for physicians of the mature minor doctrine.  J Pediatr, 1991;11: pp 520-525
  3. McCabe MA, Rushton CH, Glover J.  Implications of the Patient Self-Determination Act: Guidelines for involving adolescents in medical decision-making.  J Adoles Health 1996: 19: pp 319-324

Paradigm case:

A 15-year-old girl present with ulcerative colitis.  She refuses the recommended subtotal colectomy and ileostomy.

Teaching modality:

Case discussion after interactive presentation.

CanMeds competencies targeted:

Medical expert