Abstract
Cognitive control is of great interest to researchers and practitioners. The concurrent association between family socioeconomic status (SES) and adolescent cognitive control is well-documented. However, little is known about whether and how SES relates to individual differences in the development of adolescent cognitive control. The current four-year longitudinal investigation (N = 167, 13–14 years at Wave 1) used multi-source interference task performance (reaction time in interference correct trials minus neutral correct trials) and corresponding neural activities (blood oxygen level dependent contrast of interference versus neutral conditions) as measures of cognitive control. SES and parenting behaviors (warmth, monitoring) were measured through surveys. We examined direct and indirect effects of earlier SES on the development of cognitive control via parenting behaviors; the moderating effect of parenting also was explored. Results of latent growth modeling (LGM) revealed significant interactive effects between SES and parenting predicting behavioral and neural measures of cognitive control. Lower family SES was associated with poorer cognitive performance when coupled with low parental warmth. In contrast, higher family SES was associated with greater improvement in performance, as well as a higher intercept and steeper decrease in frontoparietal activation over time, when coupled with high parental monitoring. These findings extend prior cross-sectional evidence to show the moderating effect of the parenting environment on the potential effects of SES on developmental changes in adolescent cognitive control.
INTRODUCTION
Adolescence is a confusing and awkward period between childhood and adulthood.1 Just as adolescence is characterized by irregularity and transition, the rules governing adolescent autonomy and responsibility are likewise inconsistent, varying between different legal realms.2 Youth advocates often fight for adolescents to be held to a reduced standard of responsibility within the criminal justice system, but for increased autonomy in medical decision making.3 Others believe the exact opposite: that adolescents should be held to the same standards as adults within the criminal justice system, but have little or no autonomy in medical decision making.4
This comment proposes that adolescents receive mitigated treatment in the criminal justice system, but be given more autonomy when making medical decisions, specifically end-of-life decisions. This proposal is supported by recent research of experts in the fields of neuroscience and developmental psychology.5 Recent research suggests that adolescents demonstrate varying decision making capacities depending on the context of the situation.6 Researchers believe that youth attain mature cognitive skills by middle adolescence.7 Adolescents can employ these cognitive skills to make important decisions under structured and controlled circumstances.8 On the other hand, research also indicates that adolescents are psychosocially immature, making it difficult for them to perceive future consequences and increasing their susceptibility to risk-taking and impulsivity.9 When forced to make quick decisions, psychosocial immaturity can lead to bad decision making.10 This is especially relevant in the criminal context when most decisions to commit crime happen quickly.11
This comment will analyze the deficiencies and capabilities of adolescent decision making in two significant legal contexts: criminal responsibility and end-of-life decision making.12 The circumstances surrounding decision making in the criminal context breed impulsive and risky decision making.13 In contrast, the circumstances surrounding end-of-life decision making are more structured and informative; thus, the tendency for adolescent impulsivity is not as much of a concern.14 Accordingly, because the circumstances between the two types of decisions vary, the law should credit adolescents with greater respect for their decision making capacities in the medical decision making context than in the criminal context.15
Part I provides background on current neuroscience and psychology studies and discusses how adolescent brain development relates to risk taking and impulsivity.16 Part II discusses the legal implications of impulsivity and rationality for adolescents within the criminal justice system and in the end-of-life decision making contexts.17 Part III builds on the work of other scholars who have pointed out that mitigated criminal responsibility and increased health care decision making for adolescents can be rationalized by looking at the very different factual and emotional contexts and the different societal interests involved in these types of decisions by specifically focusing on end-of-life decision making.18
I. EFFECT OF BRAIN DEVELOPMENT ON ADOLESCENT DECISION MAKING
A. Current Status of Adolescent Neuroscience and Psychology Studies
Adolescence is the period from ages twelve through seventeen, when a young adult matures into adulthood.19 Aside from physical maturation during adolescence,20 the brain also matures.21 During this time, the adolescent brain undergoes dramatic changes.22 Professor Laurence Steinberg, a well-known researcher on adolescent cognitive development, proposes that these changes occur in two systems: the socioemotional system and the cognitive control system.23 According to Steinberg, the socioemotional system "is localized in limbic and paralimbic areas of the brain ... "24 The socioemotional system is responsible for the processing of emotions and balancing of reward versus punishment.25 The cognitive control system is located in the prefrontal cortex, with further localization in the lateral prefrontal cortex.26 The cognitive control system has been attributed to higher executive functioning activities such as impulse control, future orientation and deliberation.27 The interplay between the two systems influences adolescent risk-taking.28
Although everyone is prone to reward seeking, this tendency is especially important for adolescents.29 This is because adolescents experience increases in reward seeking, which translates into vulnerability for risky behavior.30 Puberty causes a restructuring of dopamine levels within the brain and "dopamingeric activity in the prefrontal cortex increases significantly in early adolescence."31 Dopamine is "a key monoamine neurotransmitter modulating reward circuitry" and "has been associated with multiple aspects of reward processing. . ."32 Dopamine influences reward seeking, strongly motivating individuals to seek rewards or engage in rewarding behavior.33 By adulthood, cognitive capacity for impulse control fully develops.34 This self-regulation, in conjunction with memory and experience, makes an adult better equipped to resist impulses towards reward seeking.35
The adolescent brain seems particularly sensitive to increases in dopamine.36 For adolescents the increase of dopamine occurs before the control systems in the prefrontal cortex mature.37 Furthermore, adolescent youth and lack of experience, makes this group less aware of risks.38 "Because dopamine plays a critical role in the brain's reward circuitry, the increase, reduction, and redistribution of dopamine receptor concentration during puberty, especially in projections from the limbic system to the prefrontal area, is likely to increase reward seeking behavior and accordingly, sensation seeking."39 Increased reward seeking occurs prior to the full maturation of the cognitive control system.40 It also occurs before connections between the limbic system and prefrontal cortex are forged.41 The simultaneous increase in reward seeking, as well as the developmental disparity between the cognitive control system and the limbic and paralimbic regions makes adolescents susceptible to greater risk-taking than adults.42
While reward seeking becomes more prevalent during adolescence, the brain also undergoes processes that strengthen the ability to self-regulate and ignore reward seeking impulses.43 These processes are known as synaptic pruning and myelination and increase connectivity between the limbic and paralimbic regions and the prefrontal cortex of the cognitive control system.44 Synaptic pruning removes weak or unused synapses and "promotes enhanced information processing capacity, speed and overall efficiency and supports complex computations within regional circuitry."45 Myelination is the process of insulating brain cell axons with myelin,46 which "enhances the efficiency of information processing by increasing the speed and fidelity of distal neuronal transmission . . . critical for the emergence of complex cognitive behavior."47 Synaptic pruning and myelination are important because they enhance adolescent brain processing and cognitive control.48 Synaptic pruning declines by age sixteen,49 but the process of myelination continues into adulthood.50 These processes improve the cognitive control system by linking brain circuitry.51 Professor Steinberg notes:
Because of synaptic pruning and the continued myelination of prefrontal brain regions, resulting in improved connectivity among cortical areas and between cortical and subcortical areas, there are improvements over the course of adolescence in many aspects of executive function, such as response inhibition, planning, weighing risks and rewards, and the simultaneous consideration of multiple sources of information.52
Thus, synaptic pruning and myelination are important because for decisions requiring cognitive skills, "and where improvement in adolescence is likely due to synaptic pruning of the frontal lobes, adolescents evince adult levels of competence by age 16."53
B. Adolescent Tendency for Risk-Taking and Impulsive Decision Making
"Decision making" is a process that does not have a single definition. It continues to be the subject of research and is not fully understood. For purposes of this comment, I rely on the model set forth by Laurence Steinberg and Elizabeth Scott. According to their research, decision making is influenced by a person's "maturity of judgment" which can be broken down into two facets: cognitive capacity and psychosocial factors.54 Cognitive capacity "shapes the process of decision making,"55 and includes: "understanding (i.e., the ability to comprehend information relevant to the decision) and reasoning (i.e., the ability to use this information logically to make a choice)."56 Furthermore, cognitive capacity involves the processing of information, deliberative thinking, and logical reasoning.57
On the other hand, psychosocial factors influence the actual outcome of the decision.58 Psychosocial factors include acceptance by peers, impulsivity, preference toward short term outcomes over long term outcomes and underestimating risks.59 Often these psychosocial factors affect an adolescent's perspective on a situation, or how he or she may perceive a situation.60 Consequently, this affects the adolescent's decision making process.61 Because decision making is affected by these factors, adolescents are often less likely to think about alternative decisions and curtail impulsivity.62 As noted earlier, an adolescent's cognitive skills are fairly mature by age sixteen,63 however, because adolescents are more prone to psychosocial immaturity, they tend to be less mature than adults when it comes to their judgment and decision making capacity.64
The following simple example demonstrates how cognitive capacity and psychosocial factors affect the decision making process:65 Imagine that a teenager is at the mall shopping with some of her friends. She wants to buy a new pair of sunglasses, but does not have the money. One friend suggests that she steal the glasses. As her friends begin to leave the store, she impulsively puts the sunglasses in her purse. She exits the store and the alarm goes off. Because adolescent cognitive skills mature before an adolescent becomes psychosocially mature, this teenager had the cognitive skills to know that stealing is against the law. She also had the cognitive capacity to know that it is wrong. However, at the moment she puts the sunglasses in her purse, she is not thinking about the future consequences of her actions. She does not think about going to jail or appearing in front of a judge. She is only thinking about the immediate reward of having the glasses she cannot afford. She is thinking about impressing her friends. She is not considering five minutes from now when she will be sitting in a police car waiting for her parents to pick her up. While she may have the cognitive capacity to make the right decision, her judgment is impaired by the factors of psychosocial immaturity.
The fact that cognitive decision making capacity matures by sixteen reveals why many adolescents have adult-level cognitive decision making capacity.66 Contrarily, decision making that requires the interaction of both the cognitive and the limbic systems, does not fully mature until the process of myelination (the connecting of all regions of the brain) is complete.67 Steinberg asserts that "[r]ecent studies of the neural underpinnings of resistance to peer influence in adolescence indicate that improvements in this capacity may be linked to the development of greater connectivity between cortical and subcortical regions, which likely facilitates the better coordination of affect and cognition."68 Therefore, because cognitive capacity develops before an adolescent becomes psychosocially mature, "adolescents may be less able to deploy their cognitive capacities as effectively as adults in exercising judgment in their everyday lives when decisions are influenced by emotional and social variables."69
Both impulsivity and sensation seeking are psychosocial factors that can affect risk-taking.70 Impulsivity refers to a low ability to self-regulate and "deficiencies in response inhibition,"71 whereas sensation seeking is defined as a willingness to take risks and participate in exhilarating experiences.72 Adolescent impulsivity is attributed to the developing prefrontal cortex.73 A recent research study focused on adolescent impulsivity found that impulsivity declines throughout adolescence.74 The study concluded that:
[t]he first half of the adolescent decade - between 10 and 15 - appears to be a time of growing vulnerability to risky behavior, as this period is characterized by relatively higher sensation seeking in the context of relatively lower impulse control; heightened sensation seeking impels adolescents toward risky activity, and immature self regulatory capabilities do not restrain this impulse.75
This study explicates that adolescents have a tendency towards impulsivity, and that the under-developed regions of the brain make them vulnerable to risky behavior.
II. LEGAL IMPLICATIONS OF ADOLESCENT RISK-TAKING
The idea that adolescent decision making capacity is influenced by both psychology and neuroscience constructs leads to debate on the amount of autonomy adolescents should be given in different legal contexts.76 Certainly, many different views exist on how adolescents should be treated within the criminal justice system and the medical decision making context.77 Some advocates argue adolescents deserve lesser punishment in the criminal justice system because adolescents are less mature than adults.78 Others advocate that adolescents who commit adult crimes should receive adult-like punishment.79 Regarding medical decision making, many argue that because adolescents' decision making is deficient compared to that of adults, adolescents should not be given autonomy in medical decision making.80 Others advocate that adolescents can make rational decisions in the medical arena and should be afforded that autonomy.81 While there are strong views on all sides, many views overlap, especially those of juvenile advocates who argue for lessened criminal responsibility, but greater autonomy in other legal contexts.
A. Mitigated Adolescent Criminal Culpability in the Most Recent Supreme Court Decisions
The notion that juveniles deserve different treatment than adults in the criminal justice system has existed for a little over a century.82 Prior to the creation of a separate juvenile justice system, youth who committed crimes were treated much the same as adults.83 Early juvenile courts were the product of the 19th century "child-saving movement."84 Proponents of this movement believed that rehabilitating youth would benefit not only the youth, but also society.85 As views shifted towards protecting youth, the concept of parens patriae, meaning "parent of the country," allowed the state to step in and provide supervision and control over delinquent youth.86 The separate criminal justice system for juveniles looks out for "the best interests of the child" by focusing on the "protection and treatment of the child and not for punishment."87
While the values driving the creation of juvenile courts were primarily rehabilitative, the emphasis on rehabilitation has slowly declined since the late 1970s.88 The United States experienced an increase in juvenile crime and violence in the late 1970s, and state legislatures responded with tougher laws against juveniles.89 These laws marked "[t]he movement away from rehabilitation and treatment and toward retribution and just desserts . . . ."90 Child advocates fought for a separate system in the late 19th century focusing on rehabilitation and compassion for children. Today's child advocates share these same ideals and still fight for mitigated criminal responsibility. Recently, new research in neuroscience and psychology has begun influencing the Supreme Court's treatment of adolescents.
In 2005, advocates for reduced juvenile culpability received a victory in Roper v. Simmons,91 when the Supreme Court announced that it is unconstitutional for juveniles to receive the death penalty.92 In its amicus brief submitted in support of eliminating the death penalty for juveniles, the American Psychological Association (APA) argued that "[d]evelopmentally immature decision-making, paralleled by immature neurological development, diminishes an adolescent's blameworthiness."93 The APA relied on a study demonstrating that adolescents performed much worse than adults in their decision making competence and indicated that relative to adults adolescents' were less able to consider alternative decisions.94 The APA stressed that neuroscience research demonstrates that the frontal lobes controlling executive functioning are the last to develop in the adolescent brain.95 This is significant because the lack of maturity in the frontal lobes impacts how the adolescent views whether a decision is in his or her best interests.96
Sixteen years earlier the Court had previously upheld subjecting juveniles to the death penalty in Stanford v. Kentucky.97 In Stanford, the Petitioners argued that "socioscientific" evidence demonstrated that juveniles' cognitive skills are less mature than adults, making deterrence less influential.98 Nevertheless, the Stanford Court ultimately rejected using scientific evidence to eliminate the death penalty for juveniles.99
Between Stanford and Roper the Supreme Court declared that executing the mentally disabled was unconstitutional in Atkins v. Virginia.100 The Roper Court, like the Atkins Court, compared the national disapproval of the juvenile death penalty to the disapproval of executing mentally disabled individuals.101 The Roper Court observed that many states had already abandoned the juvenile death penalty.102 Furthermore, new developments in neuroscience and psychology influenced the Court's reasoning that clear differences exist between adolescents and adults.103 Focusing on scientific studies, as well as the amicus briefs submitted in support of abolishing the juvenile death penalty, the Court held that executing juveniles is cruel and unusual punishment.104
In differentiating between adolescents and adults, the Court noted that adolescents are often perceived as immature and irresponsible,105 susceptible to peer pressure,106 and have not yet attained the attributes of a fully developed character.107 "Their own vulnerability and comparative lack of control over their immediate surroundings mean juveniles have a greater claim than adults to be forgiven for failing to escape negative influences."108 The Roper Court further reasoned that the purposes of retribution and deterrence behind the death penalty are not as compelling when applied to juveniles.109 In its conclusion, the Court remarked that "[t]he differences between juvenile and adult offenders are too marked and well understood to risk allowing a youthful person to receive the death penalty despite insufficient culpability."110
Five years after Roper, juvenile advocates received another victory in Graham v. Florida.111 In Graham, the Supreme Court held that imposing juvenile life sentences without parole for non-homicide crimes is cruel and unusual punishment and therefore violates the Eighth Amendment.112 The Graham Court began with the same analysis put forth in Roper, by observing the nation's attitude towards juvenile life sentences without the possibility of parole.113 Although hesitant to rely completely on the national consensus, the Court noted that six states forbid life sentences without the possibility parole for juvenile offenders.114 The Court declared, however, that despite the lack of legislation prohibiting this sentencing practice, national disapproval is showcased by only 123 juveniles serving life sentences without the possibility of parole for committing crimes other than homicide.115
Counsel for Graham, in both its brief and oral argument, focused on the scientific studies demonstrating adolescent immaturity and susceptibility to peer pressure.116 Using these arguments as a foundation, the Graham Court looked to the Roper Court's reasoning that adolescents typically lack maturity and do not fully understand the consequences of their actions.117 During oral argument, Chief Judge Roberts conceded that, "[w]e know that juveniles are not the worst of the worst, for the reasons you have articulated, that they are not fully developed, [and] don't have moral sense to the same extent as an adult."118 The Graham Court relied heavily on the amicus briefs submitted in support of abolishing juvenile life sentences without the possibility of parole.119 The Court noted that "developments in psychology and brain science continue to show fundamental differences between juvenile and adult minds."120 The Court reasoned further that juvenile life sentences without the possibility of parole are unconstitutional because the penological justifications of deterrence and retribution are not met in the case of juvenile offenders.121 This conclusion was informed by Roper and also acknowledged that not only are juveniles less culpable but "the same characteristics that render juveniles less culpable than adults suggest . . . that juveniles will be less susceptible to deterrence."122
Roper v. Simmons marked an enormous milestone for mitigating the culpability of juveniles within the criminal justice system.123 Roper is an important decision because it struck down the death penalty for crimes committed by juveniles, but is also noteworthy for its reliance on psychology and neuroscience studies.124 The Supreme Court again relied on psychology and neuroscience studies when it declared life sentences without the possibility of parole unconstitutional in Graham v. Florida, and similarly recognized the lessened culpability of adolescents.125 Following Roper, commentary debated whether science would inform the Court's future decision making in cases involving adolescents. 126 The Court's decision in Graham and continued reliance on adolescent brain development demonstrated that the use of neuroscience in Roper was not merely accidental. In the future, support for neuroscience and psychology will most likely continue to influence the Court's reasoning regarding juvenile punishment, and may also begin to affect other areas of juvenile law.127
B. An Argument that Impulsivity and Sensation Seeking Cannot Be Deterred
The American criminal justice system recognizes that individuals who commit crimes have varying levels of blameworthiness.128 Although there are some situations where "culpability is mitigated when the actor's decision-making capacity is diminished, when the criminal act was coerced, or when the act was out of character[,]"129 there is hesitation to reduce culpability based on mental differences.130 In Roper v. Simmons, the Supreme Court articulated that juveniles and adults are very different.131 These differences include increased risk-taking and deficient impulse control which result in an adolescent's diminished culpability in the criminal justice system.132
Some utilitarians would argue against diminished adolescent culpability in the criminal justice system based on an adolescent's inability to control impulses.133 The crux of this argument is that the social cost caused by crime outweighs any potential differences exhibited between adolescents and adults.134 Proponents of lessened criminal culpability for juveniles argue the opposite.135 For example, the APA's amicus brief in Roper questioned the deterrent value that the death penalty has on juveniles due to their impulsivity and failure to recognize long-term consequences.136
The Atkins v. Virginia decision also supports the belief that harsh punishment has no deterrent effect on deficient impulse control.137 In Atkins, the Supreme Court struck down the death penalty as unconstitutional for mentally disabled people.138 The Court reasoned that because the mentally disabled "have diminished capacities to understand and process information, to communicate, to abstract from mistakes and learn from experience, to engage in logical reasoning, to control impulses, and to understand the reactions of others" they should be treated differently than the average criminal.139 Further, the Court recognized that the death penalty would serve no deterrent effect because the cognitive and behavioral deficiencies that mitigate culpability for the mentally disabled are the same deficiencies that make it unlikely that this type of punishment will have any impact on them when they engage in crime.140
Relying on Atkins' articulation of mitigated culpability, the Roper Court recognized that "the same characteristics that render juveniles less culpable than adults suggest as well that juveniles will be less susceptible to deterrence."141 Research demonstrates that adolescents tend to act impulsively, engage in risk-taking, and do not fully consider the consequences of their actions.142 These psychosocial factors are virtually the same characteristics the Supreme Court found compelling in Atkins.143 Therefore, because adolescents are deficient at controlling impulses, and often do not think about the long-term consequences of their actions, harsh punishment will likewise have little to no deterrent effect on this group of people.
C Medical Decision Making: Adolescent Autonomy and Decision Making Capacity
Typically, adolescents are not considered capable of making medical decisions under United States law.144 One reason for this alleged incapability results from parens patriae; as described earlier, this paternalistic doctrine is premised on looking out for the "best interests of the child."145
In contrast, an international consensus exists under Article 12 of the Convention on the Rights of the Child stating that a child should have the opportunity to express his or her views in all matters affecting the child.146 Although the international community believes that children should be given deference by appropriately balancing the child's age and maturity, the United States maintains a paternalistic approach regarding medical decision making and has yet to ratify the treaty.147
In the U.S., the relatively few exceptions to this paternalistic rule are: emancipation,148 emergency,149 and the mature minor doctrine, which often applies to abortions.150 Emancipated minors are able to make medical decisions because their legal status demonstrates the capability to make decisions without parental consent.151 While emancipation recognizes adolescent autonomy, the emergency exception was instituted to protect doctors from legal liability, not in recognition of adolescents' decision making capacity.152
The mature minor doctrine allows adolescents who demonstrate an adult-level of maturity to make decisions that are traditionally reserved exclusively for adults.153 Most often the mature minor doctrine is applied only after an adolescent has engaged in typical adult-like behavior, such as pregnancy or marriage.154 For example, following the decision in Bellotti v. Baird,155 courts began applying this doctrine to adolescents seeking an abortion.156 The mature minor doctrine also applies when the adolescent's conduct may have a public health impact.157 For example, adolescents are able to obtain contraception and medical treatment for sexually transmitted diseases without parental consent.158 Notably, this exception results from concerns over public health, rather than a conclusion that adolescents possess unusual maturity relative to sexual matters.159 This exception "promotes adolescent access to treatment, preventing spread of the disease by eliminating the deterrent of having to inform a parent or guardian of sexual activity."160
While the mature minor doctrine accounts for an adolescent's ability to seek medical treatment for reproductive rights, it has rarely been applied to allow adolescents to consent or refuse life-sustaining treatment.161 Life sustaining treatment is medical care rendered for a terminally ill patient or any situation in which an individual requires medical care to sustain viability.162
1. Legal Background of End-of-Life Decision Making and the Role of the Adolescent
The case law regarding end-of-life decision making is limited. In 1990, the Supreme Court was faced with a right to die case.163 In Cruzan v. Director, Missouri Department of Health, the Court held the Due Process Clause allows for competent adults who are able to fully express their wishes to end life-sustaining medical treatment.164 Courts have been reluctant to grant a similar right to minors believing that adolescents are not competent to make end-of-life decisions.165 Doctors and parents may involve the minor in discussions about end-of-life decisions, but in most cases the minor's preferences are honored only when the parents agree.166
Some jurisdictions acknowledge the importance of the mature minor doctrine, and have allowed mature adolescents to refuse life-sustaining treatment. For example, the Illinois Supreme Court's holding in In re E.G.167 held that minors may decide to discontinue life-sustaining treatment if clear and convincing evidence establishes the minor is fully cognizant of the consequences surrounding the decision.168 The Court did not rely on scientific studies, but reasoned that the state's parens patriae interest is greater when the minor is younger and presumptively more immature, but the parens patriae interest gradually diminishes as the minor gets older.169 Similar to the general trend of case law, most state statutory provisions do not directly vest minors with the right to consent to or terminate life sustaining treatment.170 Although not referencing life-sustaining treatment specifically, many states allow minors to consent to medical treatment absent parental consent where the adolescent is emancipated, pregnant, or a parent.171 In contrast, New York's Public Health Statute § 2994-e provides not only that an emancipated minor has the ability to make their own decisions regarding life-sustaining treatment, but where a minor demonstrates the decision making capacity to choose to withhold or withdraw life-sustaining treatment, the parent's choice to the contrary cannot be implemented without the consent of the adolescent.172
2. Informed Consent Can Lead to Rational Decisions in Medical Decision Making
Informed consent in the medical decision making context is defined as the ability to consent to treatment knowingly and voluntarily, after receiving sufficient information regarding the treatment.173 The following attributes are important for a decision maker to have when making a medical decision: 1) understanding the circumstances surrounding the decision, 2) the ability to think about alternatives to the decision, and 3) ability to communicate his or her decision to others.174 Researchers suggest that an adolescent's capacity for medical decision making is based on the ability to perceive the consequences of the decision, the understanding of medical disclosure, ability to make a decision in his or her best interests, and the ability to understand the importance attached to the decision.175
Medical literature suggests that adolescents at the age of fourteen are capable of making rational decisions about their medical treatment.176 One author notes that an adolescent in need of palliative care will often times already have gained a rapport with his or her doctor.177 Because of this relationship, the adolescent will likely be competent to discuss medical treatment decisions with the doctor.178 Physicians can "play an active role in cultivating decision-making capacity in seriously ill adolescents through listening, addressing concerns, and providing counsel as they are helped to understand their options."179
Further research suggests that most adolescents want to participate in end-of-life decision making.180
Most adolescents who want to participate in the decisionmaking process ... especially in regard to decisions about life-sustaining medical interventions ...[have] experienced years of physical and psychological suffering ... probably observed the suffering and dying of several hospitalized friends with similar medical problems, these adolescent patients are frequently mature beyond chronological years. They have had, at the very least, multiple opportunities to think about the inescapable suffering that characterizes their lives, the features of life that make it worth continuing, the benefit and burdens that accompany medical treatment, and the prospect of death.181
Some scholars suggest that incorporating advanced directives into the informed consent process for adolescents facing end-of-life decisions would not only recognize adolescent autonomy but would also provide legal protection for the treating doctor.182
3. Formalized Process and Procedure in End-of-Life Decision Making Eliminates the Risk ofImpulsivity or Risk-Taking.
End-of-life decision making is a very structured and formalized process.183 Different treatment care plans arise from the diagnosis of a lifethreatening condition.184 Some care plans will include curative or lifeprolonging treatments, while other plans will focus on palliative care.185 The Institute of Medicine of the National Academies advocates for care plans that integrate both life-prolonging treatments and palliative care.186 Crucial to all care plans is re-evaluation of goals and the treatment plan itself.187 Adolescents in the midst of end-of-life decisions have numerous people to turn to for advice and guidance.188 "Depending on the situation, physicians, nurses, social workers, psychologists, child-life specialists, chaplains, and others will have roles to play" in advising and assessing the minor's end-of-life goals.189 These individuals are directed by practice guidelines and protocols that define their advising roles to adolescents during end-of-life decision making.190 Additionally, almost all hospitals have an ethics committee that can provide further guidance with end-of-life decisions.191
When the decision is made to move towards an inpatient palliative care program, an individual care plan and regular care team (consisting of the people listed above) are formed.192 The team may include a palliative care consultant.193 The palliative care consultant assists the family and adolescent patient understand their available options (e.g., transitioning to hospice care, "starting or not starting mechanical ventilation").194 The consultant also assists with evaluating the goals for end-of-life care, aids the patient with re-evaluating the care plan, and helps with transitions to hospice care if necessary.195
III. HARMONIZING IMPLICATIONS OF JUVENILE AUTONOMY WITHIN THE DIFFERENT LEGAL REALMS
Is it possible to rationalize reduced adolescent responsibility in the criminal justice system while having increased responsibility in other aspects of the legal system? As noted earlier, ample debate surrounds adolescent treatment in the criminal justice system, and many strongly advocate for adult-like treatment.196 For those who advocate for mitigated treatment within the criminal justice system, the question becomes what level of treatment should the adolescent be given when it comes to medical decision making?197 Recent studies on adolescent risk-taking and impulsivity conducted by experts in adolescent cognitive development inform the view that juveniles can be afforded differing levels of responsibility in different legal situations.198 These different levels of responsibility are based on the type of decision, and more importantly, on the circumstances of each situation.199 Research conducted by Steinberg et al., asserts that adolescents demonstrate cognitive abilities similar to adults in some situations, but lack maturity relative to adults in other situations.200
The abilities to engage in logical reasoning and comprehend information are important to cognitive decision making.201 With respect to these aspects, by sixteen an adolescent's ability to engage in cognitive decision making is comparable to an adult.202 Some studies even suggest that adolescents are capable of engaging in cognitive decision making as early as fourteen.203 Despite cognitive maturity, scholars assert that an adolescent's judgment when making decisions is influenced by the delayed maturation of their psychosocial abilities.204
For an adolescent, the decision to commit a crime and the decision of whether to consent to or refuse life-sustaining treatment are very different.205 An adolescent's decision making capacity is decision and context specific.206 Because of the circumstances surrounding criminal activity, decisions to engage in criminal activity are often spontaneous, impulsive, and only take into account the short-term positives.207 In contrast, end-of-life decision making, specifically consenting to or refusing life-sustaining treatment, involves first-hand experience of using lifesustaining treatment.208 Adolescents with life-threatening illnesses will often have a realistic view of death because of their personal experiences.209 Most importantly, the circumstances surrounding these decisions are structured and involve informed consent.210 Additionally, these decisions are made in consultation with a team of experts, and in most cases these professionals have been involved in the decision making process from the time of the life-threatening diagnosis.211 Informed consent and the active participation of the health care professional team prevent impulsive action by ensuring the decision maker is fully aware of both the consequences of the decision and the possible alternatives.212 Informed consent and the structured environment provided by health care professionals points to a crucial difference between a situation involving criminal activity and the very important decision of consenting to or discontinuing life-sustaining treatment.213
As previously discussed, research demonstrates that adolescents in situations involving social and emotional arousal deficiently consider the long-term consequences of an action and lack the ability to consider the alternatives to a decision.214 Hence, because criminal situations require hasty responses, adolescents are at risk for making poor decisions.215 These circumstances make adolescents most vulnerable to the psychosocial factors of peer pressure, risk-taking, impulsivity and difficulty with future goal orientation.216 Informed consent and the controlled circumstances surrounding end-of-life decision making make up for the inadequacies in the psychosocial maturity of adolescents.
The decision to maintain or cease life-sustaining treatment is a deliberate decision requiring logical reasoning and comprehension abilities.217 Research has demonstrated that adolescents who are at least sixteen are capable of these abilities and some studies suggest adolescents who are fourteen are capable of these abilities as well.218 End-of-life decision making requires extensive thought and is a decision that is not made spur of the moment.219 The context for end-of-life decision making is significantly different than the context for criminal activity. The most obvious actors involved in end-of-life decision making are parents, but even if parents are minimally involved in the decision, the adolescent's doctor is required to obtain the informed consent of the adolescent.220 Additionally, as described earlier, aside from parents and doctors, adolescents have numerous other professionals available to advise and assess the minor's end-of-life goals.221 Also discussed earlier, adolescents with life threatening illnesses typically establish a relationship with their treating physician, which further assists the adolescent to obtain an intelligent perspective on the situation.222 "As patients mature during adolescence, they become capable of more abstract thinking and can comprehend more complex aspects of their situations."223 Scholars advocate the importance of enhancing autonomy and making adolescents feel involved in the decision making process.224 Scholars also argue that "[o]lder adolescents having greater functional competence should be given a more central role in their decisions from the beginning."225
End-of-life decision making varies incredibly from the types of decisions that adolescents Simmons and Graham engaged in when each of them chose to commit criminal acts. Decisions to commit a crime almost always occur "in situations that elicit impulsivity, that are typically characterized by high levels of emotional arousal or social coercion, or that do not encourage or permit consultation with an expert who is more knowledgeable or experienced."226 All of these factors render adolescents, who are already vulnerable to risk-taking and impulsive behavior, more vulnerable to engaging in antisocial behavior.227 Because juvenile crime usually occurs without adults present, situations where adolescents can consult with a responsible adult and become informed of the consequences of engaging in criminal activity are rare.228 Adolescents, who are already emotionally and socially immature, become more vulnerable in these situations, accounting in part for the separate juvenile justice system.229 Although in recent years, more adolescents have been automatically placed in the adult criminal justice system230 current case law supports the once held belief that adolescents are different than adults.231 It is important to note that low psychosocial maturity is the distinction that renders juveniles less culpable in the criminal justice system.
In contrast, cognitive maturity and its relation to the structured circumstances of the medical decision make adolescents more responsible in this decision making context.232 The Supreme Court's reliance on scientific studies in analyzing adolescent psychosocial maturity in Roper and Graham is particularly telling.233 The Supreme Court used these studies to mitigate adolescent culpability in Roper v. Simmons and then most recently relied on these studies again in Graham v. Florida, indicating that the Court is starting to believe that juveniles are deserving of different treatment in the criminal context.234
CONCLUSION
This article analyzed the inconsistencies involved in adolescent decision making autonomy.235 First, this article focused on the new developments in neuroscience and psychology that reveal a scientific justification for the typical "reckless teenager."236 Support for using science as the decisive factor in determining how much responsibility an adolescent should have has not escaped criticism.237 The best approach for determining adolescent responsibility in any given legal realm is to consider developmental science.238 New research indicating adolescent tendency for impulsive behavior should be viewed in conjunction with the circumstances surrounding the legal decision being made.239
Adolescents should be give decision making autonomy in end-of-life decision making because these decisions are structured, do not require immediate response and allow the adolescent time and resources to become informed of all possible consequences and alternatives.240 Like most health care decisions, this type of decision involves informed consent.241 Thus, the adolescent's decision making will be structured and guided by formalized processes and extensive consultation with informed professionals over time.242 Therefore, the adolescent will become aware of all possible consequences to make a knowledgeable, reflective decision.243 Contrarily, scenarios involving criminal activity lend themselves to impulsive and reckless behavior.244 Adolescents in these situations need to think fast, and do not have the benefit of an authority figure weighing the costs and benefits for them.245 Because of this reality, adolescents should have reduced culpability in the criminal justice system.246 In recent cases the Supreme Court has looked to studies in neuroscience and psychology to mitigate adolescent responsibility in the justice system.247 As more advances in scientific studies become available, it is likely that science will continue to inform the Supreme Court and policy makers.
When determining adolescent responsibility, the circumstances of crime and susceptibility of adolescents to engage in crime renders them less culpable than adults. The circumstances surrounding end-of-life decision making are much more forgiving of adolescent psychosocial immaturity and provide circumstances where adolescents can use their cognitive capabilities.