Early in the pandemic, 16-year-old Megan Kosar was working at an ice cream shop in Woodbridge, Virginia. The shop required customers to wear face masks, and a customer who didn’t want to wear one began screaming at her.
“It was scary, and it was one of my first weeks at the job,” Kosar says. Today she works at a tanning salon and still hears from irate customers who oppose masks. The difference is that now she’s eligible for a COVID-19 vaccine, which would reduce her risk of infection from those who won’t mask up.
Kosar is among the estimated 25 million adolescents age 12 to 17 in the U.S. eligible to receive the Pfizer-BioNTech vaccine, which was authorized for emergency use in this age bracket on May 10. Soon, the Moderna vaccine may be available to teens, too, after clinical trial results showed that it is also safe and effective for adolescents.
The catch is that, while the Pfizer vaccine is readily available to her in her home town, she still faced a significant barrier: her parents. They worried about the potential long-term side effects of the vaccine, and they didn’t consider the coronavirus as serious a threat as she did, Kosar says.
Most states require a parent’s or legal guardian’s consent for anyone under 18 to get a vaccine, including the COVID-19 shot. So what happens when a teen wants the vaccine but their parents won’t allow it? And when should a minor have the right to get any recommended vaccines their parents oppose?
The first answer depends on the state. But the second raises a host of thorny issues at the intersection of bioethics, the law, individual risk of disease, public health, and community responsibility. And it’s an issue that potentially millions of teens may face.
According to an ongoing survey from the Kaiser Family Foundation, about a quarter of parents of adolescents ages 12 to 17 say they will “definitely not get them vaccinated.” Between 10 and 18 percent (depending on age of the child) will only vaccinate them if their school requires it. Only about a third of parents plan to get their children vaccinated right away. The rest will “wait a while to see how it is working.”
It’s not surprising that some parents who were enthusiastic about getting the vaccine themselves may be more hesitant about their children getting it, according to Maya Goldenberg, an associate professor of philosophy who studies vaccine hesitancy at the University of Guelph in Ontario, Canada. According to the CDC, adolescents have one-sixth the chance of being hospitalized and one-tenth the risk of dying from COVID-19 compared to young adults ages 18 to 29. Given those statistics and existing polarization about this issue, “there’s going to be all kinds of disagreement about how necessary are these vaccines,” Goldenberg says.
But low risk is not no risk, says Hina Talib, an associate professor of pediatrics and obstetrics-gynecology who specializes in adolescent medicine at The Children’s Hospital at Montefiore in New York City. Teens get more severe multisystem inflammatory syndrome in children (MIS-C)—a rare but serious complication of COVID-19 that causes inflammation in internal organs, and which may have long term effects on the heart, she says.
“It’s important that teens not be an afterthought in the discussion about being protected from COVID-19 because it does affect them,” Talib says. “They should absolutely be offered this vaccine.”
What medical decisions can teens make
For most medical interventions in someone under 18, it’s ethically and legally necessary to get consent from the parent or legal guardian, according to Ruth Faden, founder of the Berman Institute of Bioethics at Johns Hopkins University. But there are exceptions.
In most state laws, she says, “there are circumstances where kids take on adult responsibilities in a way that affects how they should be able to manage their medical care on their own.”
Those circumstances include treatment for mental health, substance use, and sexual and reproductive health, such as contraception or treatment for sexually transmitted infections (STIs), says Ross Silverman, a professor at Indiana University School of Law in Indianapolis.
Sometimes a teen will only seek care if their parents’ permission isn’t required, he explains. Then it’s in the best interest of the teen and public health to receive confidential care. Other unique situations, such as teens who are homeless, living on their own, or are parents themselves, also may not require parental consent.
“It’s been a piecemeal process for the development of these policies,” Silverman says, and vaccines haven’t garnered legislative attention until recently.
Interest has grown, however, because of the human papillomavirus (HPV) vaccine, which protects against multiple cancers that can develop years after an HPV infection. Since HPV is sexually transmitted, some states allow teens to get the vaccine without parental consent. Minors age 12 and older in Illinois and California, for example, need consent for all vaccines except those for HPV and hepatitis B, another STI.
But state laws regarding vaccination and consent remain a patchwork. In South Carolina, for example, teens age 16 and older can get vaccinated without parental consent, but seven states require legal guardian consent for anyone under 18 to get any vaccine.
“This is a case where what may be the ethically right thing to do may be constrained by the law,” Faden says.
In a 2019 article in the New England Journal of Medicine, Silverman and two colleagues argued that laws allowing adolescent vaccination without parent permission “could improve rates of vaccination against highly infectious diseases such as measles.” But what age is most appropriate? Some states already use 12 as the baseline, but a 2016 survey of adolescent care providers suggested 14 as the ideal age for self-consenting to vaccines.
A law passed in 2020 in Washington, D.C., allows minors age 11 and older to get any vaccine recommended by the CDC, including the COVID-19 vaccine, as long as the minor can give informed consent. Age 11 is when the CDC recommends three vaccines: HPV, meningococcal, and the Tdap shot against tetanus, diphtheria, and pertussis.
“Even though you’re a teenager, you are your own person, and you’re entitled to be concerned about your health and to protect your health,” says Mary Cheh, the councilmember who introduced the D.C. bill. “A young person shouldn’t be trapped by ideas that might cause them grave harm, with which they don’t agree, and it’s not just about them and their health—they could transmit it to other people.”
Teens feel responsibility to their communities
Concern for others is what drove Ethan Lindenberger to turn to Reddit for help catching up on his vaccinations after he turned 18. His mother, an anti-vaccine advocate, strongly opposes vaccines because she believes false claims that they can cause brain damage and other harms. (National Geographic reached out to Ethan’s mother for comment but did not receive a reply by publication.)
“My mentality was getting these vaccines is so important because it’s not just about me, it’s also about other people,” says Lindenberger, who has several younger brothers he wanted to protect. “At no point was it about rebellion. All of it was about the responsibility I had to take care of my health and the health of my community.”
Lindenberger says it felt “illogical, unfair, and uncaring” to be denied a medical intervention that protects others, and he emphasized the importance of medical autonomy to adolescence.
“Giving teenagers and young adults the option and the autonomy to make those decisions really helps equip them for moving into adulthood and shows them they have responsibilities to take care of themselves and their community by getting vaccinated,” says Lindenberger, who testified before Congress in 2019 about the dangers of vaccine misinformation.
It was predicaments like Lindenberger’s that inspired Kelly Danielpour, a California high school senior, to create VaxTeen, an organization that educates teenagers about vaccines, state consent laws, and tips for talking to parents.
“I quickly realized how difficult it was for [teens] to find answers both about getting up-to-date on vaccines and minor consent laws, as well as how complicated the issue was,” Danielpour says.
VaxTeen’s suggestions on talking to parents were exactly what Kosar, the Virginia 16-year-old, needed.
“Originally, they said No, we’re never going to back down,” she says. “But I’m very hard-headed. If there’s something I want, I work very hard to get what I want.” And with the resources from VaxTeen, she was able to prepare for her parents’ questions. It took two or three conversations to persuade them, but she eventually did. She advises other teens who want to follow in her footsteps to remain calm, wait for the right moment, and listen first to why their parents are saying no.
That’s exactly what Robin Gurwitch, a psychologist and professor at Duke University Medical Center, recommends.
“Part of the discussion is to take a step back and at least acknowledge where their parents are coming from: a place of caring,” Gurwitch says. Parents should similarly hear their teen out to validate them and send the message that their voice matters. Gurwitch says it may also help to involve a mutually trusted third party, such as the teen’s pediatrician, a family friend, or a faith-based leader.
“There’s a balance to be struck between supporting developing adolescents’ autonomies and skills for taking care of themselves, as well as empowering parents to have their role as the most important adult in adolescents’ lives,” says Talib, the adolescent medicine pediatrician. “As pediatricians, we can help open up the conversation.”
COVID-19 vaccine’s benefit for adolescent mental health
Though the COVID-19 vaccine explicitly protects a teen against the disease, a potentially bigger benefit is to their mental health, according to Talib and Gurwitch.
Research suggests that during the pandemic, teens have suffered from increased anxiety, depression, and loneliness. A recent report from the nonprofit Fair Health found that mental health insurance claims for teens age 13 to 18 doubled in March and April of 2020 compared to those months the previous year. For every subsequent month of 2020, claims were at least 19 percent higher than the previous year.
“Teens have really felt the emotional impact of this pandemic in ways that adults haven’t in terms of losing their touch points for normal development, whether it be school, internships, jobs, socialization with friends, and dating,” Talib says. “Their lives have been changed a lot, and this vaccine is bringing them one step closer to having a return of normalcy. It gives them safe opportunities to socialize and go through normal adolescent development in a way that the pandemic stunted.”
Teens may also want to get the vaccine so they can once more be around family they haven’t visited for fear of infecting them, Gurwitch says. “If they’re worried and anxious and concerned, then the vaccine provides them that level of increased security that I will be okay and that my friends and family will also be okay.”
Those were precisely the reasons Kosar wanted to get vaccinated.
“I wanted to help everybody return to as close to normal as we can get as soon as possible,” Kosar says. “I miss hanging out with my friends and feeling safer about it rather than having to worry if someone is sick.”
But she also understands why it was hard for her parents to concede some control over her health decisions. “I think they’re starting to see I’m forming my own views on how I want to take care of myself,” Kosar says. “I guess they see me as growing up. It’s scary for them when I make my own decisions.”
Kosar received her second dose of the Pfizer-BioNTech vaccine May 8, and it’s had exactly the effect she hoped for.
“It’s feeling like we’re getting back to how it was in 2019 and early 2020,” she says. “I wanted everything to try to return to normal, so it’s refreshing to me.”