Should teens call the shots on the HPV vaccine?

Not too long ago, I sat in a middle school biology classroom and read about Edward Jenner successfully using cowpox material to introduce immunity to smallpox in 1796, paving the way for development of an effective vaccination.

I found it fascinating that we could harness the effectiveness of our body’s own immune system to prevent disease without ever being infected in the first place. I was even more impressed that through comprehensive vaccination efforts, we could completely eradicate dangerous diseases.

Since that first vaccine, scientists have developed an expansive array of vaccines to fight a variety of illnesses. Yet despite these recent advances and developments, vaccines have also garnered a controversial reputation with some members of the lay public, contributing to lower than desired vaccination coverage of preventable diseases.

One vaccine that has drawn negative attention is the human papillomavirus (HPV) vaccine. The HPV vaccine protects against human papillomavirus, a sexually transmitted infection that can cause genital warts, cervical, and oropharyngeal cancers.  Although it is recommended between ages 9-11 for boys and girls, vaccination rates consistently fall short of public health goals.

Individual level factors for low HPV vaccination rates are well documented, including the belief that children are “too young” for the vaccine and the misperception that the vaccine would encourage early initiation of sexual activity.  However, system level barriers also contribute to low vaccination rates, such as the need for parental consent.

Should adolescents be able to consent to the HPV vaccine without a parent present?  While it‘s understood parents should make most medical decisions for their still-maturing children, existing exceptions already exist – often surrounding an adolescent’s sexual health.

Adolescents are already able to consent to diagnosis and treatment of sexually transmitted infections (STIs), a position with solid support from numerous professional medical associations. It seems logical to extend adolescent self-consent to prevention of sexually transmitted infections as well, especially considering the individual and public health benefit of preventing cancer.

Some states have already changed the laws to allow adolescents to consent to prevention of STIs.  In 2011, Governor Jerry Brown signed into law AB499, which explicitly permits adolescents to consent to confidential medical services for the prevention of STIs, including the HPV vaccine. Other states that have laws similar to that of California include Alabama, Arkansas, Kansas, and Montana.

Recent proposed legislation brings this issue even closer to home. Representative Sarah Davis proposed HB97-S, which would allow minors to consent to vaccines that prevent cancer, including the HPV vaccine. Both the California bill and recent Texas bill were met with considerable controversy.

How does the controversy hold up against ethical analysis? My mentor and I examined this issue in a recent paper in the Journal of Medical Ethics. We argue that ethical appeals that justify permitting adolescent self-consent to diagnosis and treatment of STIs, namely the public health benefit and adolescent’s developing autonomy, similarly justify allowing adolescents to consent to prevention of STIs -such as via the HPV vaccine.

Despite this strong ethical justification, heterogeneity among current state laws often leads to confusion amongst providers on whether adolescents may self-consent for the HPV vaccine.

Legislation providing for ethically supportable medical decisions are often met with resistance. However, in the face of such controversy, advocates for vaccines should side with fields central to medicine – science and ethics. Let’s hope we can convince law makers and the public to side with us, too.

-By Suchi Agrawal, third-year medical student at Baylor College of Medicine