UST Law Review

*This should not be treated as a medical advice. It is always best to consult your physician.

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By: Ashley Faye S. Cruz**

        You are a 15-year-old high school kid lining up in an annual physical examination. The school physician asked if you were vaccinated when you were still a newborn. You answered in the negative, and the physician gave you flyers for free vaccines at the public health center. You went home and excitedly told your mother about this thing called “vaccine” and how it can help your immune system. Your mom, who believes in medical conspiracy theories, adamantly denied your request and pulled a litany of conspiracy theories taken from social media websites. Determined, you went to the public health center, but the nurse denied you a free vaccine because there needs parental consent.

        It is very alarming that the Philippines could have avoided diseases by a simple vaccine trip to the nearest pediatrician. United Nations International Children’s Emergency Fund (UNICEF) reported that as of 2019, an estimated 2.9 million Filipino children remain unvaccinated and remain vulnerable to serious diseases such as rubella and polio. [1]

        World Health Organization (WHO) representative Rabindra Abeyasinghe said that to halt the proliferation of disease in the country, 95% need to be vaccinated[2]. Notwithstanding the availability of free vaccines at public health centers, many parents still refuse to vaccinate their children. Parents have the “vaccine hesitancy”, which is the delay in acceptance or refusal of vaccines despite the availability of vaccination services.[3] Studies have identified several factors that have caused the loss of public confidence in vaccine, though the recommended vaccines are long proven to be effective.[4] Among these are the following:

1. 1. Dengvaxia controversy, where 10% of the 800,000 students who were immunized with a vaccine against Dengue known as Dengvaxia, but did not have a prior dengue infection, posed a higher risk of contracting severe Dengue[5];
   2. Circumstantial events surrounding vaccinations such as when parents attach significance to events such as sleep or behavioral patterns and birth timing;
   3. Over-reporting of adverse effects of immunization by mass media such as newspapers and television; and
   4. Social media also contributed to vaccine hesitancy, and parents tend to be more susceptible to media reports on the Internet.[6]
2.  

        Parents who choose not to vaccinate their children endanger not only themselves but also everyone else as immunization rates fall too low for vaccine-preventable diseases. In the school year before the COVID-19 outbreak in the United States (U.S.), the rate of childhood vaccine exemptions claimed by parents rose in 40 of 49 states as reflected in the records. [7] Dr. Arthur Caplan, founding director of the Division of Medical Ethics at New York University Langone Medical Center, said that “Parents should not have the authority to subject their children to serious preventable harm”. [8]

        However, there is a solution made by certain states in the U.S. to combat the ever-worsening disease statistics. Nine states allow minors to receive vaccinations without their parents’ permission. Four states allow adolescents to receive specific vaccines, while five states allow minors to consent to any healthcare. [9] The American Medical Association and the Society for Adolescent Health and Medicine and other medical organizations, strongly support laws allowing older minors to self-consent to vaccinations. Granting teenagers this right is essential to stemming the spread of diseases, whether they are newly emerging like COVID-19 or have faded from the news.[10]

        English, et al., of the Society for Adolescent Health and Medicine, stated in their position paper Adolescent Consent for Vaccination: A Position Paper of the Society for Adolescent Health and Medicine, that adolescent vaccines allow the enhancement of adolescent and adult health. Approaches to boost the proportion of adolescents who receive vaccines will be essential to assure that adolescent vaccination will lead to developments in the health of populations. Within ethical and legal guidelines, it will be important to develop policies and strategies that expand opportunities for minors to receive vaccinations when parents are not physically present.”[11]

        The U.S. laws on emancipation from parental authority vary from state to state. For instance, some states adopt the “mature minor” doctrine. The mature minor doctrine legally recognizes the medical decision-making capacity of adolescents, even though they are still minors under parental or legal guardian control. They are usually 12 years old or older, and they are required to demonstrate adequate cognitive maturity and capacity to understand the risks of medical evaluations and treatments. Some other states allow this practice but its application is restricted only on the grounds of parental availability and sensitive clinical situations.[12] They also allow medical service without parental consent in times of emergency. Other medical services that are available to adolescents that do not need parental consent are rape or sexual assault services, contraception services. sexually transmitted infections, prenatal care, abortion, pediatric care for children of minors, substance use disorder treatment, and mental health treatment. [13]

Federal law of the U.S, does not contain any requirements for parent’s consent for vaccination of minors. As an exception, the mature minor doctrine which developed from jurisprudence provides an avenue for minors to obtain vaccines for themselves, as long as the patient can give informed consent, the treatment is not high risk, and is provided in a nonnegligent manner.[14]

        To illustrate, in the case of In Re: Swan, Maine Supreme Judicial Court addressed the issue of discontinuing the treatment of minor patient in a chronic vegetative state with little hope of recovery, specifically that the medical decision maker here is the minor patient himself. Chad had an accident which rendered him needing a life-sustaining procedure included a gastrostomy tube that provided hydration and nutrients to his body. Chad’s mother and brother said that prior to his accident, Chad told them that he did not want to be held alive by artificial means if an injury rendered him incapable of existing otherwise. The tube eventually deteriorated and made his condition worse. Chad’s parents acquiesced to his wishes.[15] The District Attorney contended that Chad’s ability to refuse medical care was “significantly limited” since he was under the legal age of majority when he articulated his wishes. Maine Supreme Judicial Court opposed such contention, saying that Chad’s age was only a “factor to be weighed by the truth finder in judging the seriousness and deliberateness” of his comments. Chad’s aspirations to not be held in a permanent vegetative condition were “well-informed medical care decisions” that should be respected.[16]

        Some suggest that all states should allow minors to make some health care decisions, especially in stigmatized areas such as sexual health and drug addiction. [17] In California, children aged 12 and up will undergo sexually transmitted disease vaccinations without parental supervision. Hepatitis B vaccine may be given to children of any age without their parents’ consent in Minnesota. In Alabama, children ages 14 and up can consent to all healthcare services.[18]

The situation in the Philippines – Emancipation Laws

        The Philippines has legislation for emancipation from parental authority. The age of eighteen years is the age of majority unless otherwise provided, and emancipation takes place in such event.[19] According to the law, “Emancipation shall terminate parental authority over the person and property of the child who shall then be qualified and responsible for all acts of civil life, save the exceptions established by existing laws in special cases.”[20]

        Parental authority is also ingrained in our statutes. Article 17 of The Child and Youth Welfare Code states that “the father and mother shall exercise jointly just and reasonable parental authority and responsibility for their legitimate or adopted children.”[21] In case of absence or death or either parent, the surviving parent shall exercise the parental authority. [22] “Grandparents and in their default, the oldest brother or sister who is at least eighteen years of age, or the relative who has actual custody of the child, shall exercise parental authority in case of absence or death of both parents unless a guardian has been appointed following the succeeding provision.”[23]

        The Code also provides in Chapter 2, Article 43  that “the parents shall have the right to the company of their children and, concerning all other persons or institutions dealing with the child’s development, the primary right and obligation to provide for their upbringing.”[24] The authority of parents/legal guardians are also strengthened by Article 209 of the Act: “Under the natural right and duty of parents over the person and property of their unemancipated children, parental authority and responsibility shall include the caring for and rearing them for civic consciousness and efficiency and the development of their moral, mental and physical character and well-being.” [25] It cannot be renounced or transferred except in cases authorized by law. [26]

        Parental authority terminates permanently upon the death of the parents, upon the death of the child, or emancipation of the child. [27] Moreover, unless subsequently revived by final judgment, it is also terminated upon adoption of the child, upon judicial declaration of abandonment of the child in a case filed for the purpose, upon the final judgment of a competent court divesting the party concerned of parental authority, upon judicial declaration of absence or incapacity of the person exercising parental authority. [28] It can be suspended upon conviction of the parent or the person exercising the same of a crime which carries with it the penalty of civil interdiction, [29] or if they treat the child with excessive harshness or cruelty, gives the child corrupting orders, counsel, or example, compels the child to beg, or subjects the child or allows him to be subjected to acts of lasciviousness

Vaccine laws in the Philippines

        There is a law mandating the basic immunization services for infants and children, or the An Act Providing For Mandatory Basic Immunization Services For Infants And Children, Repealing For The Purpose Presidential Decree No. 996, As Amended (Republic Act No. 10152). It is the policy of the State to take a proactive role in the preventive health care of infants and children, and through this legislation, the State wants to adopt a comprehensive, mandatory and sustainable immunization program for vaccine-preventable diseases for all infants and children.[30] This law covers the following vaccine-preventable diseases:

1. 1. 1. Tuberculosis
      2. Diphtheria, tetanus, and pertussis;
      3. Poliomyelitis;
      4. Measles;
      5. Mumps;
      6. Rubella or German measles;
      7. Hepatitis-B;
      8. H. Influenza type B (HIB); and
      9. Such other types may be determined by the Secretary of Health in a department circular.

 

        Such basic immunizations shall be given for free at any government hospital or health center to infants and children up to five (5) years of age.[31] R.A. 10152 also mandates that all health care practitioners or health care workers who are administering prenatal care shall educate all pregnant mothers on the importance of giving their infants the basic immunization services as well as any possible effects of immunization and that the Department of Health (DOH) and other government and private sectors shall make available appropriate information materials and shall have a system of its distribution to the public.[32] One of the important provisions is Section 5 which provides that any physician, nurse, midwife, nursing aide or skilled birth attendant, who delivers, or assists in the delivery of, a newborn shall, before delivery, inform parents or legal guardian of the newborn of the availability, nature, and benefits of immunization against Hepatitis-B and other vaccine-preventable diseases at birth.[33]

        However, Secretary to the Cabinet Karlo Nograles said that “the government could neither force parents to have their children vaccinated nor punish them if they have not.” He said that “RA 10152 does not have any penal provisions and does not punish parents who do not have their children vaccinated, unlike the Presidential Decree (PD) it replaced. Under PD 996, it was the duty of parents or those having custody of the child to see to it that the child is immunized. Those who did not could be punished with a P200 fine or one-month imprisonment” [34]

        With the advent of R.A. 11166 or the Philippine HIV and AIDS Policy Act, the threshold of consent for the screening, voluntary testing, and treatment for human immunodeficiency virus infection, was lowered to fifteen years of age— a characterization of the mature minor doctrine. It requires the assent of the child below 15 years old or those mentally incapacitated, if capacity to assent exists, in order to avail of voluntary testing and protect its interests.

        As seen from the aforementioned laws, just like at the federal level of the US, there is a vacuum in terms of parental consent for vaccination of minors in the Philippines.

Philippine laws: parental consent for medical treatments

        A doctor-patient relationship is a form of contract. It is an elementary principle that one of the elements of a contract is consent. The person giving consent must be of legal age (18 years of age, unless otherwise provided) and mentally and physically competent. As the legal guardians, parents are the persons who must sign the consent forms.[35]

        Article 1327 of the Civil Code provides the persons who cannot give consent to a contract: unemancipated minors and insane or demented persons, and deaf-mutes who do not know how to write. [36] The Civil Code does not define who can consent to a contract, rather, it defines who has no capacity. These persons can easily be victims of fraud as they are not capable of understanding or knowing the nature of their actions, thus they can only enter into an agreement or contracts through their parents or their legal guardians.[37] The contract they have entered is voidable, meaning it is valid and binding until it is annulled by a proper action in court.[38]

        In the medical field, there is the right to informed consent,  a legal right recognized and protected by law and jurisprudence. The patient has the right to choose openly whether or not to consent to care after being adequately advised by the specialist about the complications and benefits of the recommended treatment, as well as the viable treatment alternatives, including the possibility of no treatment.[39] It is further drawn as a legal concept, where a person can be said, “to have given consent based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action.” He must have adequate reasoning faculties and knows all relevant facts at the time consent is given. If a person cannot give informed consent, say a child, another person is generally authorized to give consent on their behalf, in this case, his parents or legal guardian/s. [40]

        The key elements of informed consent, according to Tejam of Asia Pacific Journal of Pediatrics and Child Health are disclosure of information, assessment of the decision maker’s capacity to make medical choices, and process of obtaining consent in the form of a voluntary agreement from the patient without coercion or persuasion. In pediatrics, it comes from the parent or legal guardian. Per the best interests standard, parents are regarded to be in the best position to determine their child’s best interest because parental decision aims to maximize benefits for their children while minimizing harm. However, the determination of what is in children’s best interest is often subjective and debatable. While written or verbal informed parental consent may be enough for ethical and legal purposes, but it does not meet the necessities of the ethical concept of informed concept. [41]

        The purpose of informed consent and the strict guidelines surrounding this concept is the respect for autonomy, which includes the liberty of the patient, defined as “the capacity to live life according to one’s reasons and motives and agency …[or] rational capacity for intentional action.” This principle served as one of the pillars in resolving ethical dilemmas.[42]

Legal consequences of letting Filipino adolescents make vaccine related medical decisions

        Suppose the teen suffered injuries because of the vaccine[43] and the parents want to file a suit against the physician who administered the vaccine. Here are some of the laws that are usually invoked in a medical malpractice suit.

Medical malpractice is defined by Bellosillo, et al (2010) as:

 “Any professional misconduct, or bad skillful practice, or any practice contrary to law or established rules and regulations whereby the health of a person is injured because of failure of a physician to behave or act as a reasonable, prudent physician who is charged with a duty to use a standard of due care and to foresee harm that may result from failure to meet such standard which may be the proximate cause of injury. It ordinarily refers to any malfeasance or dereliction of duty committed by a physician.”[44]

The elements of medical malpractice, as enunciated in the case of Lucas vs Tuaño, (2009), are:

1. 1. 1. A patient engages the services of a physician whereby a physician-patient relationship is generated
      2. A physician is under a duty to [the former] to exercise that degree of care, skill, and diligence which physicians in the same general neighborhood and the same general line of practice ordinarily possess and exercise in like cases
      3. There is a breach of duty of care, skill, and diligence, or the improper performance of such duty, by the attending physician when the patient is injured in body or health
      4. Proof of such breach must likewise rest upon the testimony of an expert witness that the treatment accorded to the patient failed to meet the standard level of care, skill, and diligence which physicians in the same general neighborhood and the same general line of practice ordinarily possess and exercise in like cases.
      5. The proximate cause of an injury is that cause, which, in the natural and continuous sequence, unbroken by any efficient intervening cause, produces the injury, and without which the result would not have occurred[45]
       

        With these elements present, the physician can be held liable for negligence which is a tort liability. Negligence is defined as “the doing of some act which a reasonable and prudent physician would not do, or the failure to do some act which such a person should or would do.”[46] While it is true that physicians are not required to possess extraordinary learning and skill, however, they must keep abreast with medical developments and techniques and must refrain from experimenting. [47]

        In terms of evidence, the patient must prove that the health care provider failed to do something which a reasonably prudent health care provider would have done, or that he or she did something that a reasonably prudent provider would not have done; and that that failure or action caused injury to the patient. [48] The injured minor or his parents/legal guardian can recover financial damages (actual damages for the pecuniary loss suffered by a party, and moral damages, for the physical suffering and/or mental anguish, fright, shock, etc.). [49]

        He can also be held criminally liable[50]. Under the Revised Penal Code (RPC), he can be liable for the crime of administering injurious substances or beverages. The elements are:

1. 1. 1. The offender inflicted upon another any serious physical injury;
      2. That it was done by knowingly administering to him any injurious substances or beverages or by taking advantage of his weakness of mind or credulity;
      3. That he had no intent to kill. [51]
       

        He can also be made liable for Physical Injuries[52] and for Reckless Imprudence (quasi-offense). Reckless imprudence, as defined in Article 365 of RPC, “consists in voluntarily, but without malice, doing or failing to do an act from which material damage results because of inexcusable lack of precaution on the part of the person performing or failing to perform such act, taking into consideration his employment or occupation, degree of intelligence, physical condition and other circumstances regarding persons, time and place.”[53]

        On the other end, the medical practitioner can take shelter on legal doctrines to save themselves from liability. The first is the doctrine of foreseeability, which provides that:

“A physician cannot be held liable for negligence if the injury sustained by a patient is on account of unforeseen conditions. But, a physician who fails to ascertain the condition of the patient for want of the requisite skills and training is answerable for the injury sustained by the patient if an injury resulted thereto. Such foreseeable injury may be ascertained from the history, physical examination, observation and from information gathered from another member of the family.”[54]

       He can also avoid liability by invoking the defense of accident, that is, an event which happens without any human agency or, if happening through human agency, an event which, under the circumstances, is unusual to and not expected by the person to whom it happened.[55]

Practical Consequences – Risks of letting minors make health care decisions

        David DeLugas, executive director of the National Association of Parents (U.S.), said that letting minors make health care decisions in lieu of their parents may introduce conflict into families. He does not think states should upset the parent-child relationship by taking power from the parents and transferring it to the children.[56]

        Grootens-Wiegers, et al. also noted that there is no general agreement as to which age is appropriate for minors to be considered competent for informed decision-making. Some studies suggest that it is at 9 years old, some studies suggest that it is ages of 14 or 15. Minors of the same age may have a different level of maturity. Young children, who exhibited an adequate aptitude for decision-making in a certain situation, can lack ample ability in another.[57]

        They also discussed that adolescence is a period when various health issues and increased risks appear. Teenagers experience changes in diet and tend to explore vices such as tobacco and substance abuse. The increase in mortality is attributed to decision-making being affected by risky behavior, sensation seeking, and peer influences. The increased risk can also be attributed to lower cognitive control because of the developing brain in adolescence, especially the brain’s reward system combined with late development of the control system which decreases decision-making competence. Since the maturity of adolescence varies from one child to another, the practice can be very unpredictable.[58]

        However, good practical outcomes can also come with the idea of minors making medical decisions for themselves, especially for vaccines. Assent from minors aged seven years and above can improve moral growth and develop autonomy. It can even encourage them to comply with the medical treatment and allow them to express their interests in such endeavor. It offers a chance to contribute to their healthcare and provide an honest and open relationship between the family and medical service team.[59] Children will no longer be obligated to keep quiet for the sake of their parents. It also ensures that a child’s unanswered questions, unresolved worries, or desire to be acknowledged are treated as legitimate and rational issues that matter in the child’s world, rather than being dismissed as complete nonsense. [60]

Recommendation

        With the positive and negative outcomes analyzed, the recommendations are set forth to guide future legislators and policymakers and to help outweigh the negative effects.

• • • The requirements of assent are: 1) properly informing patients about the issues at hand and what to expect; 2) assessment of their understanding; 3) soliciting agreement or acknowledgment of the decision.[61]
    • American Academy of Pediatrics said that assent should be obtained whenever reasonable, and that assent should only be obtained in situations in which the medical service team would be willing to honor, at least in part, a child’s dissent.[62]
    • Legislation should reflect the concept of care ethics (“Individuals do not exist in isolation but with others to  whom  they are emotionally or psychologically close,  such as parents,  siblings, and friends ”). Medical professionals should educate a minor by generating information that can provide specific medical context that can be weighed and analyzed with perspectives offered by family and friends which can largely affect their thought processes. The legislation should also recognize the limitations of judgments of minors.[63]
    • The legislators should also limit the age bracket (ideally at the age of 14), and limit the vaccines to the recommended types that have been long proven to be effective by science (Ex. measles, polio, diphtheria, influenza) to minimize health risks.
    • In the legislation, healthcare professionals, adolescent health care clinicians, public health personnel, medical organizations should be present and give their inputs.[64]
    • The legislators should frame the law in a way that reflects the thought that “parental consent should be considered a responsibility that supports the minor’s best interests and preserves a family’s interests, rather than a parent’s right to express their own autonomous choices.”  Davis and Fang, in an article, said that “Providers have to serve the pediatric patient’s best interest and not necessarily the parents’ desires.”[65]
    • For policy-making among healthcare professionals or even in the legislation itself, a set of protocols should be developed to serve as a guide to assess minor’s maturity and decision-making ability. Legal documentation guidelines should be executed to protect healthcare workers against a suit.[66]
    • Adolescent’s privacy should be reflected in the legislation and healthcare protocols. [67]
     

Conclusion

        Vaccines have greatly contributed in eradicating serious diseases that could have led to mortality or permanent disability. They are one of the scientific breakthroughs that are gravely misunderstood and often subjected to prejudicial preference. Time and again refused because of misinformation as well as cultural and religious differences. In the Philippines, there is a huge vacuum in emancipation laws for medical decisions for minors. Assuming that minors would be allowed to obtain a vaccine without parental consent, different positive outcomes could be factored, such as a decrease in disease statistics and empowerment in adolescence, while negative outlooks include increased risky behavior in minors because of their developing mental and physical structure, and the boosted risk of medical malpractice suits if ever the vaccine produces adverse effects in their body. Legislators should strive to include healthcare workers in developing legislation that would allow minors to get vaccines for themselves without parental permission, all while preserving the family harmony and the patient’s well-being, as well as knowing that this is about a patient’s health and not grandstanding parental authority.

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* Associate Research Editor, UST Law Review; freelance writer

[1]UNICEF Philippines, #VaccinesWork: UNICEF stresses importance of immunization on World Immunization Week, UNICEF Philippines, (January 31, 2021), https://www.unicef.org/philippines/press-releases/vaccineswork-unicef-stresses-importance-immunization-world-immunization-week

[2] Jenny Lei Ravelo, Another casualty of vaccine hesitancy: Philippines declares polio outbreak, (January 31, 2021), https://www.devex.com/news/another-casualty-of-vaccine-hesitancy-philippines-declares-polio-outbreak-95648

[3] Department of Health, Doh Identifies Vaccine Hesitancy as One of The Reasons For Measles Outbreak, Department of Health, (January 31, 2021), https://doh.gov.ph/node/16721

[4] Id.

[5] World Health Organization, Revised SAGE recommendation on use of dengue vaccine, (Apil 19, 2018), https://www.who.int/immunization/diseases/dengue/revised_SAGE_recommendations_dengue_vaccines_apr2018/en/

[6] Migrino, Jr J, Gayados B. Birol RJ, De Jesus L, Lopez CW, Mercado WC, et al. Factors affecting vaccine hesitancy among families with children 2 years old and younger in two urban communities in Manila, Philippines. Western Pac Surveill Response J. 2020 Jun; 10(2). doi: 10.5365/wpsar.2019.10.2.006

[7] Kelly Danielpour, Commentary: Why all 50 states need to allow teens to get vaccinated without parental consent, Los Angeles Times, (Nov. 19, 2020), https://journaltimes.com/news/commentary-why-all-50-states-need-to-allow-teens-to-get-vaccinated-without-parental-consent/article_264a2b69-0924-5c08-aabd-fb79fa5deec4.html

[8] Id.

[9] Michael Ollove, Teens of ‘Anti-Vaxxers’ Can Get Their Own Vaccines, Some States Say, Stateline, (June 24, 2019), https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/06/24/teens-of-anti-vaxxers-can-get-their-own-vaccines-some-states-say

[10] Kelly Danielpour, Commentary: Why all 50 states need to allow teens to get vaccinated without parental consent, Los Angeles Times, (Nov. 19, 2020), https://journaltimes.com/news/commentary-why-all-50-states-need-to-allow-teens-to-get-vaccinated-without-parental-consent/article_264a2b69-0924-5c08-aabd-fb79fa5deec4.html

[11] Abigail English, Carol A. Ford, Jessica A. Kahn, Elyse Olshen Kharbanda, Adolescent Consent for Vaccination: A Position Paper of the Societyfor Adolescent Health and Medicine, 53 Journal of Adolescent Health, 550, 550-553, (2013)

[12] Michael Davis & Andrea Fang, Emancipated Minor, StatPearls Publishing LLC, (May 19, 2020), https://www.ncbi.nlm.nih.gov/books/NBK554594/

[13] Id.

[14] Abigail English, Carol A. Ford, Jessica A. Kahn, Elyse Olshen Kharbanda, Adolescent Consent for Vaccination: A Position Paper of the Societyfor Adolescent Health and Medicine, 53 Journal of Adolescent Health, 550, 552, (2013)

[15] In Re: Chad Eric Swan, 569 A.2d 1202 (1990), decided January 23, 1990, opinion Issued February 15, 1990.

[16] Id.

[17] Michael Ollove, Teens of ‘Anti-Vaxxers’ Can Get Their Own Vaccines, Some States Say, Stateline, (June 24, 2019), https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/06/24/teens-of-anti-vaxxers-can-get-their-own-vaccines-some-states-say

[18] Mackenzie Bean, 9 states where minors can get vaccinated without parental consent, ASC COMMUNICATIONS 2021, (June 24, 2019), https://www.beckershospitalreview.com/quality/9-states-where-minors-can-get-vaccinated-without-parental-consent.html

[19] An Act Lowering The Age Of Majority From Twenty-One To Eighteen Years, Amending For The Purpose Executive Order Numbered Two Hundred Nine, And For Other Purposes, Republic Act No. 6809, sec. 234 (1989)

[20] R.A. 386, sec. 236

[21] The Child and Youth Welfare Code, Presidential Decree No. 603, art. 17 (1974)

[22]P.D. 603, art. 17

[23] P.D. 603, art. 19 (1974)

[24] P.D. 603, art. 43 (1974)

[25] The Family Code of The Philippines, Executive Order No. 209, art. 209 (1988)

[26] E.O. 209, art. 210

[27] E.O. 209, art. 228

[28] E.O. 209, art. 229

[29] E.O. 209, art. 230

[30] An Act Providing For Mandatory Basic Immunization Services For Infants And Children, Repealing For The Purpose Presidential Decree No. 996, As Amended, Republic Act No. 10152, sec. 2 (2011)

[31] R.A. 10152, sec. 3

[32] R.A. 10152, sec. 4

[33] R.A. 10152, sec. 5

[34] Sheila Crisostomo & Gilbert Bayoran, Mandatory immunization ordered, The Philippine Star, (Feb. 10, 2019), https://www.philstar.com/headlines/2019/02/10/1892465/mandatory-immunization-ordered

[35] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 113, (2010 ed. Central Book Supply, 2010)

[36] An Act To Ordain And Institute The Civil Code Of The Philippines, Republic Act No. 386, art. 1327 (1950)

[37] Hector S. De Leon & Hector M. De Leon, Jr. The Law on Obligations and Contracts, p. 342-349, (Rex Printing Company, Inc., 2014)

[38] Id. at p. 431

[39] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 113, (2010 ed. Central Book Supply, 2010)

[40] Id. at p. 412 (2010 ed. Central Book Supply, 2010)

[41] Cyrus Cesar R. Tejam, Clinical Pediatrics in the Philippines: Parental Assent and Consent, 2 Asia Pacific Journal of Pediatrics and Child Health, 27, 29  (2019)

[42] Id.

[43] An instance is when it is recommended that “vaccines not be given during chemo or radiation treatments – the only exception to this is the flu shot. This is mainly because vaccines need an immune system response to work, and you may not get an adequate response during cancer treatment.” – American Cancer Society, Vaccinations and Flu Shots for People with Cancer: Should people with cancer get any vaccines? , American Cancer Society webpage, Inc. (2020), https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/low-blood-counts/infections/vaccination-during-cancer-treatment.html. This should not be treated as a medical advice. It is always best to consult your physician.

[44] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 117 (2010 ed. Central Book Supply, 2010)

[45] Lucas v. Tuaño, 586 SCRA 173 (2009)

[46] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 131, (2010 ed. Central Book Supply, 2010)

[47] Id.

[48] Professional Services, Inc. v. Natividad and Enrique Agana, 542 Phil. 464, 481 (2007).

[49] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 59, (2010 ed. Central Book Supply, 2010)

[50] Id at 195

[51] The Revised Penal Code, Act No. 3815, art. 264, (1930)

[52] Act No. 3815, art. 266, (1930)

[53] Gonzaga v. People, G.R. No. 195671, January 21, 2015.

[54] Josue N. Bellosillo, Bu C. Castro, Emmanuel LJ. Mapili, Albert D. Rebosa, Antonio D. Rebosa, Basics of Philippine Medical Jurisprudence and Ethics, p. 154, (2010 ed. Central Book Supply, 2010)

[55] Id.

[56] Michael Ollove, Teens of ‘Anti-Vaxxers’ Can Get Their Own Vaccines, Some States Say, Stateline, (June 24, 2019), https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/06/24/teens-of-anti-vaxxers-can-get-their-own-vaccines-some-states-say

[57] Petronella Grootens-Wiegers,  Irma M. Hein, Jos M. van den Broek, & Martine C. de Vries, Medical decision-making in children and adolescents: developmental and neuroscientific aspects, BMC Pediatrics, 1, 2 (2017)

[58] Petronella Grootens-Wiegers,  Irma M. Hein, Jos M. van den Broek, & Martine C. de Vries, Medical decision-making in children and adolescents: developmental and neuroscientific aspects, BMC Pediatrics, 1, 6 (2017)

[59] Cyrus Cesar R. Tejam, Clinical Pediatrics in the Philippines: Parental Assent and Consent, 2 Asia Pacific Journal of Pediatrics and Child Health, 27, 29 (2019)

[60] Rebecca Babcock, Medical Decision-Making for Minors: Using Care Ethics to Empower Adolescents and Amend the Current Power Imbalances, 8 Asian Bioethics Review, 4, 13 (2016)

[61] Cyrus Cesar R. Tejam, Clinical Pediatrics in the Philippines: Parental Assent and Consent, 2 Asia Pacific Journal of Pediatrics and Child Health, 27, 29 (2019)

[62] Id at 27-33

[63] Rebecca Babcock, Medical Decision-Making for Minors: Using Care Ethics to Empower Adolescents and Amend the Current Power Imbalances, 8 Asian Bioethics Review, 4, 13 (2016)

[64] Abigail English, Carol A. Ford, Jessica A. Kahn, Elyse Olshen Kharbanda, Adolescent Consent for Vaccination: A Position Paper of the Society for Adolescent Health and Medicine, 53 Journal of Adolescent Health, 550, 552, (2013)

[65] Michael Davis & Andrea Fang, Emancipated Minor, StatPearls Publishing LLC, (May 19, 2020), https://www.ncbi.nlm.nih.gov/books/NBK554594/

[66] Id.

[67] Id.

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