03-02-23 - Children and Young People Flashcards
Learning outcomes
- Recognise the developing autonomy of young people and the impact that has on medical decision-making
- State the age at which it is legally assumed that young people can make decisions about their care
- Describe the principle of best interests in relation to medical decision-making in children
- Explain why parents who are Jehovah’s Witnesses come into conflict with medical professionals over blood transfusion for their children
- Appreciate why the case of Jodie & Mary was particularly complicated with regards to the best interests test
- Describe what is meant by a Gillick-competent young person
- Explain, using either the lock/key or flak jacket analogy, why treatment can go ahead, even if a young person does not give their consent
- Outline the ethical issues raised by living organ donation, euthanasia and clinical research in children & young people
What is the GMC 0–18 years: guidance for all doctors?
- GMC 0–18 years: guidance for all doctors:
- “The law relating to children and young people is complex and differs across the UK. Doctors who have children and young people as patients will need some understanding of the law as it applies where they practise. Summaries of the law contained in this guidance cannot be a substitute for up-to-date legal advice in individual cases”
How can we determine capacity and consent in children and young people?
What is developing in young people?
What must we seek to do for young people?
- To determine capacity and consent in children and young people, we can use function or status (or a mix)
- Status – type of patient e.g psychiatric patient
- Function – state of the person to make decisions e.g a concussed persons can make decisions on their behalf
- In young people, autonomy is developing
- We must seek to support and yet also protect – therein lies the tension
What do we mean by “children & young people” in the UK?
- Children and young people in the UK:
- People under the age of 18 in England, Wales & Northern Ireland
- People under the age of 16 in Scotland
- “At 16 it is legally presumed that young people have the ability to make decisions about their own care.”
Who makes decisions if the child lacks capacity?
What can happen if these decisions don’t promote the welfare of the child?
- If a child lacks capacity, parents make decisions, but decisions are constrained by best interests of the child
- If they are not seen to be making a decision that promotes the welfare of the child, then their wishes can be overridden
- If assent (approval) can be given, it should be sought
In addition to clinical best interests, what 6 things should we consider when thinking about the best interests of the child?
- 6 things should we consider when thinking about the best interests of the child? (in addition to clinical best interests):
1) The views of the child or young person, so far as they can express them, including any previously expressed preferences
2) The views of parents
3) The views of others close to the child or young person
4) The cultural, religious or other beliefs and values of the child or parents
5) The views of other healthcare professionals involved in providing care to the child or young person, and of any other professionals who have an interest in their welfare
6) Which choice, if there is more than one, will least restrict the child or young person’s future options
Describe The child who lacks capacity: Case 1 – when doctors and parents disagree (Re S)
- The child who lacks capacity: Case 1 – when doctors and parents disagree
- Re S (Parents - Jehovah’s Witnesses)
- S was 4 ½ years old with T cell leukemia
- Undergoing chemotherapy & blood transfusion would improve recovery
- Parents refused (religious & safety reasons)
- Refusal overruled
Describe The child who lacks capacity: Case 2 – when doctors and parents disagree (Re A)
- The child who lacks capacity: Case 2 – when doctors and parents disagree (Re A):
- If they remained together, they would both die
- If separated, Jodie would live, Mary would die
- Doctors wanted to act to separate, parents did not allow
- High court, then court of appeal - Separation took place
When is a child referred to as being ‘Gillick competent’?
How is Gillick competence determined?
- “a young person under 16 with capacity to make any relevant decision is often referred to as being ‘Gillick competent’.”
- As per adults: The child is Gillick competent if they can understand, retain, use/weigh this information, & communicate decision, however:
- “”…it is not enough that she should understand the nature of the advice which is being given: she must also have a sufficient maturity to understand what is involved.“
What is an important consideration when assessing for Gillicks competence?
- Important consideration when assessing for Gillicks competence:
- “It is important that you assess maturity and understanding on an individual basis and with regard to the complexity and importance of the decision to be made. You should remember that a young person who has the capacity to consent to straightforward, relatively risk-free treatment may not necessarily have the capacity to consent to complex treatment involving high risks or serious consequences. The capacity to consent can also be affected by their physical and emotional development and by changes in their health and treatment.”
Why is consent more easily accepted than refusal?
- Consent is more easily accepted than refusal because of the flak jacket analogy
- We only need 1 flak jacket to be protected legally
- This can be given to us by:
1) Mature minor
2) Parents (right co-exists)
3) Courts
Describe The mature minor case: Refusal of life-saving blood transfusion on religious grounds – overruled (Re E)
- The mature minor case Refusal of life-saving blood transfusion on religious grounds – overruled (Re E)
- 15 yr old boy Jehovah’s witness – refused blood transfusion for his leukaemia Not enough to know he would die, but must understand the “manner of his death and the extent of his and his family’s suffering” (higher standard than adults?)
- Note: on turning 18, he refused further transfusions and died
- Once he turned 18, his best interest no longer applied as he is now competent
Describe The mature minor case: Hannah Jones (refusal of heart transplant after long term illness) – upheld
- The mature minor case: Hannah Jones (refusal of heart transplant after long term illness) – upheld
- PCT sought court order for heart transplant for 13 yr old girl (she had refused to undergo the transplant – her parents agreed with her decision)
- Child protection officer said Hannah was adamant Refusal respected
- (note: agreed to transplant the following year, and is currently doing well)
How do the rules of organ donation apply to those under 16 in Scotland and the rest of the UK?
What was the BMAs stance on this?
- In Scotland, anyone under the age of 16 (competent or not) cannot be a living donor
- In England, Wales and N. Ireland solid organ donation by living children is permitted
- BMA were opposed, now support so long as young person is competent to give valid consent & is not under coercion (BMA’s Handbook of E & L, 2012)
How does euthanasia apply to young people in the Netherlands and Belgium?
- In the Netherlands, euthanasia is legal for those over the age of 12 (with permission of their parents) – the Dutch Paediatric Association has now called for age limit to be lifted altogether (June 2015)
- Belgium lifted all age restrictions in 2014
