Week 7- Children & refusal of consent

Question 1

Can a refusal of consent of a minor, including 16 and 17yrs, be overturned?

Answer 1

Their refusal of consent can be overridden in their best interests to avoid death or severe permanent injury by a court or parents

This also includes 16 and 17yr olds

Question 2

Do both parents need to give consent for a minor?

Answer 2

Doctor only needs consent of one person to continue

–Competent child OR one OR other parent/person with parental responsibility.

Question 3

What happens if refusal is by a 16 or 17 year old?

Answer 3

• Presumption in favour of capacity under MCA
• Recommended that Trusts seek the opinion of the Court of Protection before disregarding a refusal of consent by minors 16 or 17, even if parental consent is available

Question 4

If a child lacks capacity to consent what should you do? (in relation to GMC 2007 guildlines)

Answer 4

27. If a child lacks the capacity to consent, you should ask for their parent’s consent. It is usually sufficient to have consent from one parent. If parents cannot agree and disputes cannot be resolved informally, you should seek legal advice about whether you should apply to the court

Question 5

Parents/ those with parental responsibility must ALSO have the capacity to make the decision at hand- when might this be a problem?

Answer 5

• Some parents are themselves minors
• Some parents may have mental impairments or disabilities that may restrict their capacity to make complex treatment decisions
• Parents may themselves be affected by e.g. the same RTA as their child

Question 6

Drs should always act in the BI of a child. How can BI be assessed?

Answer 6

–a. the views of the child or young person, so far as they can express them, including any previously expressed preferences

–b. the views of parents

–c. the views of others close to the child or young person

–d. the cultural, religious or other beliefs and values of the child or parents

–e. 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

–f. which choice, if there is more than one, will least restrict the child or young person’s future options.

Question 7

What should you do before seeking legal advice when you believe treatment in the interest of the child is refused?

Answer 7

Consult colleagues

Question 8

What does the Children Act 1989 section 1.1 say?

Answer 8

the child’s welfare shall be the court’s paramount consideration.

Question 9

If a child who hasn’t got capacity needs to have medical intervention what is the general expectation of the parents, courts and doctors?

Answer 9

Parents are expected to, and courts MUST, make decisions on the basis of what is all things considered best for the child – ‘best interests’

Doctors when offering advice on medical options must also do so in the child’s best interests

Question 10

Give one reason why the BI of a court may differ from that of a parent with multiple children

Answer 10

Parents may have the same obligation to more than one child – they may have the balance the interests of all their children when deciding what to do.

–Doctors, like courts, are expected to act in the best interests of the patient before them

Question 11

When the court is faced with a situation where the BI of minors are in tension how is a decision made?

Answer 11

•Will decide on the basis of the minor on whose behalf the case has been bought

Question 12

What are the parental authority ethical considerations?

Think about the legal aspect and the HRA

Answer 12

• Parents are legally responsible for the care of their children
• They must, therefore, have authority necessary to exercise this responsibility
• They also have a right to ‘private and family life’ (art 8 HRA)
• Threshold for interference in parental authority is ‘good enough’ parenting
• This gives parents considerable latitude in how they raise their children

Question 13

The child’s BI is multifactoral:

It inccludes the need for child to develop his/her capacity for autonomy. What does this mean in the context of health? And what does this mean for parents and Drs?

Answer 13

• Thus children may be permitted to experiment with e.g. self care even though this may put their health at some risk
• Neither parents nor doctors should be over-bearing

Question 14

If a child who lacks capcity is disregarding their preferences over-riding their autonomy? And why?

Answer 14

• NOTE: there is a difference between the exercise of autonomy and the mere expression of preference.
• A child who lacks capacity is not autonomous; disregarding their preferences is not over-riding their autonomy because they have no autonomy

Question 15

What are the Dr’s professional obligations when tx a child without capacity?

Answer 15

•To act in the child’s best interests

•Recognising that these are multifactorial including:

– that the interests of children may be bound to those of their parents and siblings

–The need to maintain a therapeutic relationship with child and parents

•Obliged to challenge parental authority through the courts but only if necessary

Question 16

What does para 14 of the GMC guidance say in relations to ‘Doctors also have to treat children with respect, involving them in discussions and decisions about their care’ (8)

Answer 16

–‘a. involve children and young people in discussions about their care

–b. be honest and open with them and their parents, while respecting confidentiality

–c. listen to and respect their views about their health, and respond to their concerns and preferences

–d. explain things using language or other forms of communication they can understand

–e. consider how you and they use non-verbal communication, and the surroundings in which you meet them

–f. give them opportunities to ask questions, and answer these honestly and to the best of your ability

–g. do all you can to make open and truthful discussion possible, taking into account that this can be helped or hindered by the involvement of parents or other people

h. give them the same time and respect that you would give to adult patients.’

Question 17

How do courts make a decision for a minor who lacks consent?

How do they consider the interest of parents and their rights/ authority as parents

How is medical advice used (Drs vs Drs and Drs vs parents)

Answer 17

• Have to look as objectively as possible at the best interests (in the round) of the child before them.
• Do not have to consider the interests of the parents as such but do have to consider their legitimate rights and authority as parents

–Can refuse to make an order

–Child’s interest are paramount

• Will be guided by doctors but may have to decide between medical opinions where doctors disagree
• Medical opinions will be considered against (e.g. child’s right to life)and the parents’ reasons for opposing the doctors’ judgement

Question 18

In high profile cases it often centres around life and death decision for the courts to make

Who else is informed in this situation and by who?

Answer 18

Courts are asked to decide AND press are informed – either by parents or, as in case of the Kings, by the police

Question 19

What other ethical circumstances raise concerns? (3)

Answer 19

• Parental refusal of immunisation
• Parental request for non therapeutic interventions e.g. male circumcision, surgical correction of physical characteristics
• Parental refusal of treatment for non life-threatening conditions

Question 20

What does the GMC and law state about procedures that do not offer immediate or obvious therapeutic benefits for children?

Answer 20

Allowed to undertake so long as in BI and performed with consent

Question 21

Imagine you have a family who want to child to be circumcised

How does GMC guidance resond to this? What should you cosnider?

Answer 21

To assess their best interests you should consider the religious and cultural beliefs and values of the child or young person and their parents as well as any social, psychological and emotional benefits