Advertisement

From Human Papillomavirus to COVID-19: Adolescent Autonomy and Minor Consent for Vaccines

Open AccessPublished:August 05, 2022DOI:https://doi.org/10.1016/j.pedhc.2022.06.007
      Adolescent minors in every state can give their own consent for some health care. Although parent consent is generally required for vaccination, there are exceptions in some states. Completion rates are low for recommended adolescent vaccines; allowing adolescents to consent may improve coverage, although more study is needed on barriers to vaccine completion and the feasibility of changes in consent laws. The COVID-19 pandemic highlights the importance of vaccines and related challenges. This policy brief reviews laws governing adolescent consent for health care, including vaccines, and recommends advocacy to support increased adolescent access to vaccines and improved public health.

      KEY WORDS

      Minimizing barriers to adolescent health care serves important public health needs. Allowing adolescent minors to consent to their care is one strategy to further this goal. Adolescents in every state can consent to diagnosing and treating sexually transmitted infections (STIs;

      Guttmacher Institute. (2022). An overview of consent to reproductive health services by young people. Retrieved from https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

      ). This approach to STIs recognizes public health risks posed by infectious disease and public interest in encouraging adolescents to seek care. Allowing adolescents to consent to vaccines can meet similar goals by preventing the transmission of preventable diseases. However, state and local policies that explicitly allow adolescent consent for vaccines are rare (
      • Zimet G.D.
      • Silverman R.D.
      • Bednarczyk R.A.
      • English A.
      Adolescent consent for human papillomavirus vaccine: Ethical, legal, and practical considerations.
      ). Although parental consent is generally required for vaccination, there are exceptions. Some states and localities already allow adolescents to consent for specific vaccines, such as human papillomavirus and hepatitis B, integrating them with treatment and prevention of STIs, for which young people in those locations can already consent, or allow self-consent for vaccines because of an adolescent's status (
      • Zimet G.D.
      • Silverman R.D.
      • Bednarczyk R.A.
      • English A.
      Adolescent consent for human papillomavirus vaccine: Ethical, legal, and practical considerations.
      ).
      The COVID-19 pandemic has clarified the public health importance of vaccines, the impact of vaccine hesitancy for the pandemic, political divisions about vaccine mandates, and divisions within families about vaccinating children (
      • Hoffman J.
      As parents forbid Covid shots, defiant teenagers seek ways to get them.
      ;
      • Lewis J.R.
      What is driving the decline in people's willingness to take the COVID-19 vaccine in the United States?.
      ). Some adolescents may wish to be vaccinated or refuse the vaccine, contrary to parental views (
      • Yang Y.T.
      • Olick R.S.
      • Shaw J.
      Adolescent consent to vaccination in the age of vaccine-hesitant parents.
      ), and may rely more on their provider's vaccine recommendations than their parents’ recommendations (
      • Griffin D.S.
      • Muhlbauer G.
      • Griffin D.O.
      Adolescents trust physicians for vaccine information more than their parents or religious leaders.
      ). A policy may be needed to resolve such differing views. Below we explore the laws and rationale underlying adolescent consent for health care, views on adolescent vaccine consent during the COVID-19 pandemic, and recommendations for increasing access to vaccines.

      CONSENT FOR HEALTH CARE BY ADOLESCENT MINORS

      Until the mid-twentieth century, minors in the United States did not have legal rights independent of their parents (
      • Schapiro N.A.
      • Mejia J.
      Adolescent confidentiality and women's health: History, rationale, and current threats.
      ). Beginning in the 1960s, court decisions recognized that minors have constitutional due process, First Amendment, and privacy rights. States simultaneously enacted laws allowing minors to consent to their health care. These laws, which vary significantly from state to state, allow adolescent minors to consent for health care either because they have a specific status (e.g., married) or living situation (e.g., homeless) or are seeking a specific service (

      English, A., Bass, L., Boyle, A. D., & Eshragh, F. (2010). State minor consent laws: A summary. Retrieved from https://www.freelists.org/archives/hilac/02-2014/pdftRo8tw89mb.pdf

      ). For example, adolescent minors in every state can consent to the diagnosis and treatment of STIs (

      Guttmacher Institute. (2022). An overview of consent to reproductive health services by young people. Retrieved from https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

      ).
      The ethical concept of autonomy supports the right to consent to or refuse health care once the adolescent has the mental capacity to understand the implications of alternatives and make a voluntary choice (
      • Beauchamp T.L.
      • Childress J.F.
      Principles of biomedical ethics.
      ). Researchers, using a well-established tool that assesses adult competence, have estimated that children reach intellectual competence to consent autonomously to research by the age of 12 years (
      • Hein I.M.
      • De Vries M.C.
      • Troost P.W.
      • Meynen G.
      • Van Goudoever J.B.
      • Lindauer R.J.L.
      Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children's competence to consent to clinical research.
      ), but opinions about the age at which adolescents may competently consent to either research or medical treatment vary (
      • Grootens-Wiegers P.
      • Hein I.M.
      • van den Broek J.M.
      • de Vries M.C.
      Medical decision-making in children and adolescents: Developmental and neuroscientific aspects.
      ), as do state laws (

      English, A., Bass, L., Boyle, A. D., & Eshragh, F. (2010). State minor consent laws: A summary. Retrieved from https://www.freelists.org/archives/hilac/02-2014/pdftRo8tw89mb.pdf

      ;

      Guttmacher Institute. (2022). An overview of consent to reproductive health services by young people. Retrieved from https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

      ;
      • Zimet G.D.
      • Silverman R.D.
      • Bednarczyk R.A.
      • English A.
      Adolescent consent for human papillomavirus vaccine: Ethical, legal, and practical considerations.
      ).

      CONSENT FOR VACCINATION OF ADOLESCENTS

      Historically, parental consent has been required for vaccinations for children and for those adolescents aged < 18 years and legally minors. There are specific circumstances in which adolescent minors may legally be able to consent to their vaccinations. State laws allowing adolescent minors to consent for their care are based on their legal status, living situations, or the services they seek. Laws in each of these categories—status and services—may be a source of support for minor consent to vaccination (Table 1).
      TABLE 1Consent for vaccination by adolescent minors
      Status that may allow minors to consent for general health care, including vaccinationServices for which minors may be allowed to consent that include vaccination
      Minors who have attained a specific agePrevention of sexually transmitted disease or infection
      “Mature minors”
      The mature minor doctrine, defined in court decisions and incorporated into statute in a few states, allows minors to consent to care if they can give informed consent.
      Prevention of infectious, contagious, or communicable disease
      Legally emancipated minors
      Minors living apart from parents, including homeless and runaway youth
      Married minors
      Minor parents (for self and/or child)
      Minors in military service
      Note. Data from

      English, A., Bass, L., Boyle, A. D., & Eshragh, F. (2010). State minor consent laws: A summary. Retrieved from https://www.freelists.org/archives/hilac/02-2014/pdftRo8tw89mb.pdf

      ;

      Guttmacher Institute. (2022). An overview of consent to reproductive health services by young people. Retrieved from https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

      ; and
      • Zimet G.D.
      • Silverman R.D.
      • Bednarczyk R.A.
      • English A.
      Adolescent consent for human papillomavirus vaccine: Ethical, legal, and practical considerations.
      .
      a The mature minor doctrine, defined in court decisions and incorporated into statute in a few states, allows minors to consent to care if they can give informed consent.
      Less clarity exists in state laws regarding whether and when adolescent minors may refuse care; however, it is often presumed that a minor can refuse care to which they could legally consent (
      • Hartman R.
      Adolescent autonomy: Clarifying an ageless conundrum.
      ). Even when the law is unclear or parental consent is required, ethically, clinicians should at minimum seek the assent of the adolescent minor. This has special relevance when a parent wants their adolescent child to be vaccinated, and the adolescent refuses (

      Hoff, T., & Kao, A. (2021). Ethics talk: Should adolescents be able to consent for COVID-19 vaccinations? Retrieved from https://journalofethics.ama-assn.org/videocast/ethics-talk-should-adolescents-be-able-consent-covid-19-vaccinations

      ).
      Overall, there are many legal and ethical reasons for allowing some adolescent minors to consent to their vaccinations, and both the American Medical Association and the Society for Adolescent Health and Medicine have advocated for expanded adolescent vaccine consent (
      • English A.
      • Ford C.A.
      • Kahn J.A.
      • Kharbanda E.O.
      • Middleman A.B
      Adolescent consent for vaccination: A position paper of the Society for Adolescent Health and Medicine.
      ;
      • Matshazi N.
      AMA backs states allowing “mature minors” to consent to vaccinations.
      ). As with other health care, authorizing minors to consent for vaccinations can serve both the public health goal of reducing the risk of transmission of infectious diseases and protecting adolescents’ health. As important as legal and policy guidance, clinical and ethical guidance is needed for these situations in which an adolescent and parent do not agree about vaccination (
      • Olick R.S.
      • Yang Y.T.
      • Shaw J.
      Adolescent consent to COVID-19 vaccination: The need for law reform.
      ).

      COVID-19 SPECIFIC ISSUES

      The emergence of parental resistance to vaccines in recent years has contributed to outbreaks of measles, pertussis, and other contagious diseases (
      • Olick R.S.
      • Yang Y.T.
      • Shaw J.
      Adolescent consent to COVID-19 vaccination: The need for law reform.
      ). This resistance has been attributed to mistrust of government and health care systems, political affiliation, religious objections, concerns about vaccine safety and, for COVID-19, disagreements about the danger of the infection, and concerns about the speed with which the vaccines were developed and approved (
      • Troiano G.
      • Nardi A.
      Vaccine hesitancy in the era of COVID-19.
      ). Despite very effective COVID-19 vaccines (
      • Olson S.M.
      • Newhams M.M.
      • Halasa N.B.
      • Price A.M.
      • Boom J.A.
      • Sahni L.C.
      Overcoming Covid-19 Investigators
      Effectiveness of BNT162b2 vaccine against critical Covid-19 in adolescents.
      ), low vaccine uptake has contributed to the continued morbidity and mortality associated with COVID-19 (Table 2). The unique nature of the COVID-19 pandemic illuminated some distinctive reasons to facilitate adolescent receipt of vaccines. In particular, the need to balance immediate public health concerns with family and adolescent decision-making is unique to COVID-19 (
      • Morgan L.
      • Schwartz J.L.
      • Sisti D.A.
      COVID-19 vaccination of minors without parental consent: Respecting emerging autonomy and advancing public health.
      ). Herd immunity created by very high rates of previous childhood vaccine completion resulted in unvaccinated and vulnerable community members being protected from most contagious diseases (

      Centers for Disease Control and Prevention. (2021). FastStats. Retrieved from https://www.cdc.gov/nchs/fastats/immunize.htm

      ). In contrast, very high rates of circulating COVID-19 virus put unvaccinated youth at risk of being infected and spreading the virus to others (
      • Willis D.E.
      • Presley J.
      • Williams M.
      • Zaller N.
      • McElfish P.A.
      COVID-19 vaccine hesitancy among youth.
      ). Because both the virus and the vaccine were new, many families were particularly hesitant about vaccinating their children and adolescents (
      • McGrew S.
      • Taylor H.A.
      Adolescents, parents, and Covid-19 vaccination—Who should decide?.
      ).
      TABLE 2COVID-19 vaccination rates in adolescents and adults as of June 9, 2022
      Age groupAt least one doseFully vaccinated
      Defined as one dose of Johnson & Johnson or two doses of Moderna or Pfizer.
      Adolescents aged 12–17 years69.6%59.7%
      Adults aged 18–24 years78.6%63.9%
      Adults aged 25–39 years80.3%67.2%
      Note. Data from the Centers for Disease Control and Prevention (updated June 14, 2022; https://data.cdc.gov/Vaccinations/COVID-19-Vaccination-and-Case-Trends-by-Age-Group-/gxj9-t96f).
      a Defined as one dose of Johnson & Johnson or two doses of Moderna or Pfizer.
      Conflicts between parents, children, and adolescents around vaccines are not novel and have intensified as vaccines have become increasingly politicized (
      • Mubarak E.
      • Firn J.
      When parents don't want their teenager to be vaccinated against COVID-19, who calls the shots?.
      ). Public health messaging about the importance of COVID-19 vaccination—and rules requiring the COVID-19 vaccine for participation in school or other activities—led some adolescents to seek vaccination despite parental hesitation (
      • Hoffman J.
      As parents forbid Covid shots, defiant teenagers seek ways to get them.
      ). In the context of the public health emergency, some states and local governments expanded adolescent rights to allow minors to consent specifically to COVID-19 vaccines (
      • Olick R.S.
      • Yang Y.T.
      • Shaw J.
      Adolescent consent to COVID-19 vaccination: The need for law reform.
      ;

      Singer, N., Kates, J., & Tolbert, J. (2021). COVID-19 vaccination and parental consent. Retrieved from https://www.kff.org/policy-watch/covid-19-vaccination-and-parental-consent/

      ).
      Although cogent arguments support allowing adolescents to consent to vaccines (
      • Agrawal S.
      • Morain S.R.
      Who calls the shots? The ethics of adolescent self-consent for HPV vaccination.
      ;
      • Olick R.S.
      • Yang Y.T.
      • Shaw J.
      Adolescent consent to COVID-19 vaccination: The need for law reform.
      ), it is unclear that expanding consent would lead to increased COVID vaccination rates. A study of young adults earlier in the pandemic found that concerns about safety and side effects were major reasons for slower vaccine uptake in this age group (
      • Adams S.H.
      • Schaub J.P.
      • Nagata J.M.
      • Park M.J.
      • Brindis C.D.
      • Irwin C.E.
      Young adult perspectives on COVID-19 vaccinations.
      ). A contemporaneous study of ninth graders found that most were either somewhat or very hesitant to get the vaccine themselves (
      • Willis D.E.
      • Presley J.
      • Williams M.
      • Zaller N.
      • McElfish P.A.
      COVID-19 vaccine hesitancy among youth.
      ).

      POLICIES TOWARD ADOLESCENT SELF-CONSENT IN THE UNITED STATES AND BEYOND

      Although adolescent consent for vaccines is supported by the ethical principle of autonomy and developmental research on adolescents, in practice, self-consent for vaccines is not widespread, either in the United States or other countries (
      • Fisher H.
      • Harding S.
      • Hickman M.
      • Macleod J.
      • Audrey S.
      Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis.
      ;

      World Health Organization. (2014). Considerations regarding consent in vaccinating children and adolescents between 6 and 17 years old. Retrieved from https://apps.who.int/iris/handle/10665/259418

      ). Fisher and colleagues noted that one barrier to self-consent was that health care providers were concerned about its impact on the provider-parent relationship.
      The

      World Health Organization. (2014). Considerations regarding consent in vaccinating children and adolescents between 6 and 17 years old. Retrieved from https://apps.who.int/iris/handle/10665/259418

      noted that factors such as accessibility and cost for vaccines had more impact on vaccine uptake than consent. Making vaccines mandatory to participate in school and other activities have increased vaccine coverage in the United States and abroad (
      • Cioffi A.
      Perspectives of vaccination in Italy: Adolescents and parental consent.
      ). Many countries use schools as a location for vaccinating children and adolescents, increasing the accessibility of vaccines, and in these countries, the time needed to obtain written parental consent is seen as a barrier to wider implementation (
      • Perman S.
      • Turner S.
      • Ramsay A.I.G.
      • Baim-Lance A.
      • Utley M.
      • Fulop N.J.
      School-based vaccination programmes: A systematic review of the evidence on organisation and delivery in high income countries.
      ). Parents in the United States have supported schools as a site for health care services, including vaccines (
      • Gargano L.M.
      • Weiss P.
      • Underwood N.L.
      • Seib K.
      • Sales J.M.
      • Vogt T.M.
      • Hughes J.M.
      School-located vaccination clinics for adolescents: Correlates of acceptance among parents.
      ), and advanced practice nurses can advocate for school-based vaccine clinics.
      Adolescents often present alone for health care, either in school or freestanding clinic settings, including for services that require parental consent. In these circumstances, policies and procedures that facilitate obtaining and tracking parental consent for vaccines could increase the uptake of COVID-19 and other essential adolescent vaccines (
      • Fisher H.
      • Harding S.
      • Hickman M.
      • Macleod J.
      • Audrey S.
      Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis.
      ;

      World Health Organization. (2014). Considerations regarding consent in vaccinating children and adolescents between 6 and 17 years old. Retrieved from https://apps.who.int/iris/handle/10665/259418

      ). Many health care systems have increased their use of electronic communication via cell phone and e-mail for a variety of forms during the COVID-19 pandemic (
      • Wood S.M.
      • White K.
      • Peebles R.
      • Pickel J.
      • Alausa M.
      • Mehringer J.
      • Dowshen N.
      Outcomes of a rapid adolescent telehealth scale-up during the COVID-19 pandemic.
      ). Expanding opportunities to obtain consent via electronic communication could ease the vaccine permission process and increase access for adolescents presenting alone. The Centers for Disease Control and Prevention guides obtaining permission for school-located vaccine programs (Box).
      Additional information on minor consent and vaccines

      Conclusions

      The COVID-19 pandemic highlighted challenges related to vaccine access and uptake for adolescents that have existed for a long time. Overcoming these challenges requires understanding and addressing the complex interplay of many legal, ethical, and clinical factors related to parental consent and adolescent autonomy. We support clarifying the COVID-19 vaccine consent policy when minors qualify for expanded health care consent under status- or service-specific laws, and increasing flexibility of parent consent options. The full exploration of current controversies about parents’ rights and adolescent privacy is beyond the scope of this article; however, they affect the feasibility of a greater expansion of adolescent consent for vaccines at this time. Increasing adolescent COVID-19 vaccine rates will require further research into the underlying reasons for the low uptake of all vaccines. In the meantime, health care professionals can play a key role in collaborative discussions with adolescent patients, their parents, and guardians about the importance and safety of vaccines, and the COVID-19 pandemic continues to provide an urgent incentive.

      References

        • Adams S.H.
        • Schaub J.P.
        • Nagata J.M.
        • Park M.J.
        • Brindis C.D.
        • Irwin C.E.
        Young adult perspectives on COVID-19 vaccinations.
        Journal of Adolescent Health. 2021; 69: 511-514
        • Agrawal S.
        • Morain S.R.
        Who calls the shots? The ethics of adolescent self-consent for HPV vaccination.
        Journal of Medical Ethics. 2018; 44: 531-535
        • Beauchamp T.L.
        • Childress J.F.
        Principles of biomedical ethics.
        Oxford University Press, Oxford, United Kingdom2013
      1. Centers for Disease Control and Prevention. (2021). FastStats. Retrieved from https://www.cdc.gov/nchs/fastats/immunize.htm

        • Cioffi A.
        Perspectives of vaccination in Italy: Adolescents and parental consent.
        Cadernos de Saúde Pública. 2020; 36e00195519
      2. English, A., Bass, L., Boyle, A. D., & Eshragh, F. (2010). State minor consent laws: A summary. Retrieved from https://www.freelists.org/archives/hilac/02-2014/pdftRo8tw89mb.pdf

        • English A.
        • Ford C.A.
        • Kahn J.A.
        • Kharbanda E.O.
        • Middleman A.B
        Adolescent consent for vaccination: A position paper of the Society for Adolescent Health and Medicine.
        Journal of Adolescent Health. 2013; 53: 550-553
        • Fisher H.
        • Harding S.
        • Hickman M.
        • Macleod J.
        • Audrey S.
        Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis.
        Vaccine. 2019; 37: 417-429
        • Gargano L.M.
        • Weiss P.
        • Underwood N.L.
        • Seib K.
        • Sales J.M.
        • Vogt T.M.
        • Hughes J.M.
        School-located vaccination clinics for adolescents: Correlates of acceptance among parents.
        Journal of Community Health. 2015; 40: 660-669
        • Griffin D.S.
        • Muhlbauer G.
        • Griffin D.O.
        Adolescents trust physicians for vaccine information more than their parents or religious leaders.
        Heliyon. 2018; 4: e01006
        • Grootens-Wiegers P.
        • Hein I.M.
        • van den Broek J.M.
        • de Vries M.C.
        Medical decision-making in children and adolescents: Developmental and neuroscientific aspects.
        BMC Pediatrics. 2017; 17: 120
      3. Guttmacher Institute. (2022). An overview of consent to reproductive health services by young people. Retrieved from https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

        • Hartman R.
        Adolescent autonomy: Clarifying an ageless conundrum.
        Hastings Law Journal. 2000; 51: 1265
        • Hein I.M.
        • De Vries M.C.
        • Troost P.W.
        • Meynen G.
        • Van Goudoever J.B.
        • Lindauer R.J.L.
        Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children's competence to consent to clinical research.
        BMC Medical Ethics. 2015; 16: 76
      4. Hoff, T., & Kao, A. (2021). Ethics talk: Should adolescents be able to consent for COVID-19 vaccinations? Retrieved from https://journalofethics.ama-assn.org/videocast/ethics-talk-should-adolescents-be-able-consent-covid-19-vaccinations

        • Hoffman J.
        As parents forbid Covid shots, defiant teenagers seek ways to get them.
        The New York Times. 2021; (Retrieved from)
        • Lewis J.R.
        What is driving the decline in people's willingness to take the COVID-19 vaccine in the United States?.
        JAMA Health Forum. 2020; 1e201393
        • Matshazi N.
        AMA backs states allowing “mature minors” to consent to vaccinations.
        Healthcare Weekly. 2019; (Retrieved from)
        • McGrew S.
        • Taylor H.A.
        Adolescents, parents, and Covid-19 vaccination—Who should decide?.
        New England Journal of Medicine. 2022; 386: e2
        • Morgan L.
        • Schwartz J.L.
        • Sisti D.A.
        COVID-19 vaccination of minors without parental consent: Respecting emerging autonomy and advancing public health.
        JAMA Pediatrics. 2021; 175: 995-996
        • Mubarak E.
        • Firn J.
        When parents don't want their teenager to be vaccinated against COVID-19, who calls the shots?.
        American Journal of Bioethics. 2022; 22: 66-68
        • Olick R.S.
        • Yang Y.T.
        • Shaw J.
        Adolescent consent to COVID-19 vaccination: The need for law reform.
        Public Health Reports. 2022; 137: 163-167
        • Olson S.M.
        • Newhams M.M.
        • Halasa N.B.
        • Price A.M.
        • Boom J.A.
        • Sahni L.C.
        • Overcoming Covid-19 Investigators
        Effectiveness of BNT162b2 vaccine against critical Covid-19 in adolescents.
        New England Journal of Medicine. 2022; 386: 713-723
        • Perman S.
        • Turner S.
        • Ramsay A.I.G.
        • Baim-Lance A.
        • Utley M.
        • Fulop N.J.
        School-based vaccination programmes: A systematic review of the evidence on organisation and delivery in high income countries.
        BMC Public Health. 2017; 17: 252
        • Schapiro N.A.
        • Mejia J.
        Adolescent confidentiality and women's health: History, rationale, and current threats.
        Nursing Clinics of North America. 2018; 53: 145-156
      5. Singer, N., Kates, J., & Tolbert, J. (2021). COVID-19 vaccination and parental consent. Retrieved from https://www.kff.org/policy-watch/covid-19-vaccination-and-parental-consent/

        • Troiano G.
        • Nardi A.
        Vaccine hesitancy in the era of COVID-19.
        Public Health. 2021; 194: 245-251
        • Willis D.E.
        • Presley J.
        • Williams M.
        • Zaller N.
        • McElfish P.A.
        COVID-19 vaccine hesitancy among youth.
        Human Vaccines and Immunotherapeutics. 2021; 17: 5013-5015
        • Wood S.M.
        • White K.
        • Peebles R.
        • Pickel J.
        • Alausa M.
        • Mehringer J.
        • Dowshen N.
        Outcomes of a rapid adolescent telehealth scale-up during the COVID-19 pandemic.
        Journal of Adolescent Health. 2020; 67: 172-178
      6. World Health Organization. (2014). Considerations regarding consent in vaccinating children and adolescents between 6 and 17 years old. Retrieved from https://apps.who.int/iris/handle/10665/259418

        • Yang Y.T.
        • Olick R.S.
        • Shaw J.
        Adolescent consent to vaccination in the age of vaccine-hesitant parents.
        JAMA Pediatrics. 2019; 173: 1123-1124
        • Zimet G.D.
        • Silverman R.D.
        • Bednarczyk R.A.
        • English A.
        Adolescent consent for human papillomavirus vaccine: Ethical, legal, and practical considerations.
        Journal of Pediatrics. 2021; 231: 24-30

      Biography

      Lisa Klee Mihaly, Associate Clinical Professor, Department of Family Health Care Nursing, School of Nursing, and Nursing Faculty, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, San Francisco, CA.
      Naomi A. Schapiro, Professor Emerita, Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, CA.
      Abigail English, Center for Adolescent Health & the Law, and Associate Adjunct Professor, UNC Gillings, Global School of Public Health, Chapel Hill, NC.