Consent in children

Current Opinion in Psychiatry

Volumn 11, Issue 4, 1998, Pages 389-393

  Dickenson, Donna L ^a  

^a IMPERIAL COLLEGE SCHOOL OF MEDICINE   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

CHILD HEALTH CARE; EMOTION; INFORMED CONSENT; MATURITY; MEDICAL DECISION MAKING; REVIEW;

EID: 0031857092     PISSN: 09517367     EISSN: None     Source Type: Journal    
DOI: 10.1097/00001504-199807000-00005     Document Type: Review

References (49)

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2. 4 All ER 627 (1992).
3. Ellertson C. Mandatory parental involvement in minors' abortions: effects of the laws in Minnesota, Missouri and Indiana. Am J Public Health 1997; 87:1367-1374. This carefully argued article convincingly demonstrates that observed declines in the adolescent abortion rate in three US states which required parental involvement in decisions to abort were largely caused by buck-passing: minors simply drove over the border to another state where parental consent was not mandatory. Where the laws did have some effect - and a medically dangerous one - was in delaying minors' abortions to past week 8, although generally not into the second trimester. Ellertson's research has little direct relevance to UK practice: the decision in Re W would, if anything, allow the reverse, whereby parents could impose an abortion on a minor without her consent (although Lord Donaldson's opinion denied that this scenario was likely). However, it is a useful reminder of how capable and adroit adolescents may be in circumventing politically motivated legislation
4. Cooper DK. Juveniles' understanding of trial-related information: are they competent defendants? Behav Sci Law 1997; 15:167-180. This depressing report again illustrates the primacy of 'moral panic' over justice or fairness. Examining a national trend lowering the age for transfer of juveniles facing criminal charges to adult courts - one state now allows this for children of 10 years who are facing the death penalty - Cooper concludes from interviews with children as young as 11 years, already experiencing their first institutional placement, that they did not have sufficient understanding for meaningful participation in their trials. The parallel in the UK is the lowering of the age of doli incapax to 10 years, against the trend in most other countries of raising the age of criminal responsibility. This, too, was politically motivated, in the wake of the murder of two-year-old Jamie Bulger by two 10 year old boys (See [5]).
5. Dickenson D. Children's informed consent to treatment: is the law an ass? J Med Ethics 1994; 20:205-206.
6. Royal College of Paediatrics and Child Health. Report of the Ethics Advisory Committee. London: Royal College of Paediatrics and Child Health; 1997. This is an important document which has received considerable media coverage, although it has been criticised by some commentators as too doctor-dominated and by others as taking children's autonomy to dangerous extremes. This probably indicates that the committee got the balance about right.
7. ••]).
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11. Sutton A. Authority, autonomy, responsibility and authorisation: with special reference to adolescent mental health practice. J Med Ethics 1997; 23:26-31. This thoughtful article by a practitioner urges his colleagues to examine their own unconscious mental processes and to ensure that patients do not become 'victim of the professional's own psychopathology', particularly in relation to adolescent mental health.
12. Harrison C, Kenny NP, Sidarous M, Rowell M. Bioethics for clinicians: 9. Involving children in medical decisions. Can Med Assoc J 1997; 156:825-828. A sensitive case study of a 'bright loving' 11 year old girl with osteosarcoma and metastasis to the lungs, who adamantly refuses the aggressive treatment her parents wish. The authors strike a balance between affirming the parents' responsibility and 'allowing the child to exercise choice in a measure appropriate to his or her level of development and experience of illness and treatment'. They argue that capacity must include 'achievement of a fairly stable set of values', as do Dickenson and Jones [13].
13. Dickenson D, Jones D. True wishes: the philosophy and developmental psychology of children's informed consent. Philos Psychiatry Psychol 1995; 2:287-305.
14. Parker M. Commentary on 'True wishes'. Philos Psychiatry Psychol 1995; 2:313-314.
15. Traugott I. In their own hands: adolescents' refusals of medical treatment. Arch Pediatr Adolesc Med 1997; 151:923-926. Three particularly newsworthy cases, of which the best known is probably that of Benito Agrelo, a fifteen year old Florida boy who refused a third liver transplant. When, with his mother's consent, he also stopped taking immunosuppressive drugs because he found the side-effects intolerable, hospital adminstrators called a child-abuse hotline, and Benito was forcibly moved into hospital. A court order finally allowed him to return home and to refuse the immunosuppressive medications; he died in August 1994, having lived what he called 'as close as I can to a natural life'.
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20. Gillick v. W. Norfolk and Wisbech AHA [1985] 3 All ER 402.
21. •, 8]). The textbook is clear and well-considered throughout, and in other areas of the law as well.
22. Devereux J, Jones DPH, Dickenson D. Can children withhold consent to treatment? Br Med J 1993; 306:1459-1461.
23. Montgomery J. Consent to health care for children. J Child Law 1993; 5:117-124.
24. Pearce J. Consent to treatment during childhood: the assessment of competence and avoidance of conflict. Br J Psychiatry 1994; 165:713-716.
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27. Bates P. Children in secure psychiatric units: Re K, W and H - 'out of sight, out of mind'?. J Child Law 1994; 6:131-137.
28. Re K, W and H [1993] 1 FLR 854.
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31. Scotland NL. Refusal of medical treatment: psychiatric emergency? Am J Psychiatry 1997; 154:106-108. This is a clinical case conference, usefully broken down into the ethical and treatment dilemmas at each stage of the case, which illustrates how other medical specialities regard refusal of treatment in children as a matter for the psychiatrist.
32. Honig P, Bentovim M. Treating children with eating disorders - ethical and legal issues. Clin Child Psychol Psychiatry 1996; 1:287-294.
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35. International Huntington Association and World Federation of Neurology Group on Huntington's Chorea. Guidelines for the molecular genetics predictive test in Huntington's disease. Neurology 1989; 44:1533-1536.
36. Clinical Genetics Society. The genetic testing of children: report of a working party. J Med Genet 1994; 31:785-797.
37. Genetics Interest Group. GIG response to the Clinical Genetics Society report. London: Genetics Interest Group; 1994.
38. Wertz DC, Fanos JH, Reilly PR. Genetic testing for children and adolescents: who decides? JAMA 1994; 272:875-881.
39. Scourfield J, Soldan J, Gray J, Houlihan G, Harper PS. Huntington's disease: psychiatric practice in molecular genetic prediction and diagnosis. Br J Psychiatry 1997; 170:146-149. This article contains a selection of anonymized cases, including one concerning a 14 year old girl at 50% risk for Huntington's disease who later reported having felt suicidal when her request for predictive testing was denied on the grounds of her age. The case is complicated by the girl's schizophrenia and history of self-harm; the discussion is frustratingly skimpy and inconclusive. However, the article is useful for its discussion of the range of psychiatric disorders, in addition to dementia, which are often associated with Huntington's disease, although most of the references are from adult psychiatry.
40. Motulsky AG. Screening for genetic diseases. N Engl J Med 1997; 336:1314-1316.
41. Spiegler GE. Genetic screening of adolescents. N Engl J Med 1997; 337:639-640.
42. McCabe L. Efficacy of a targeted genetic screening program for adolescents. Am J Hum Genet 1996; 59:762-763.
43. Mitchell JJ, Capua A, Clow C, Scriver CR. Twenty-year outcome analysis of genetic screening programs for Tay Sachs and betathalassemia disease carriers in high schools. Am J Hum Genet 1996; 39:793-798.
44. Meehan TM, Hansen H, Klein WC. The impact of parental consent on the HIV testing of minors. Am J Public Health 1997; 87:1338-1341. An instructive examination of the consequences after young people in Connecticut, USA, themselves mobilized against moral panic measures requiring parental consent for HIV testing, and succeeded in altering the law. The authors' conclusion from comparison of 1600 HIV test site visits before and after the parental consent requirement was repealed is short and sweet: 'Minors should have the right to consent to HIV testing', because denying them that right is counter-productive on efficiency grounds.
45. ••], adding a further dimension by comparison with minors' access to abortion, contrasting consent to diagnostic versus treatment services.
46. Ford CA, Millstein SG, Halpern-Feischer BL. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care: a randomized controlled trial. JAMA 1997; 278:1029-1034.
47. Sikand A, Schubiner H, Simpson PM. Parent and adolescent perceived need for parental consent involving research with minors. Arch Pediatr Adolesc Med 1997; 151:603-607. A survey of 100 adolescents and their parents at a Detroit children's hospital.
48. Nelson RM. Ethics in the intensive care unit: creating an ethical environment. Crit Care Clin 1997; 3:691-701. The author rightly stresses everyday ethics in paediatric intensive care: 'we are often left with the false impression that ethics only comes into play in problematic situations existing at the margins of our technical skill, rather than in our everyday care of critically ill patients'. Specific common problems that are considered, in addition to informed consent in children, include conflict between doctors and nurses, which doctors may not even be aware of: one study cited found that whereas doctors who were asked about significant ethical problems in their experience related stories about their individual uncertainty, nurses, when asked a similar question, recounted narratives of interprofessional conflict.
49. Larcher VF, Lask B, McCarthy JM. Paediatrics at the cutting edge: do we need clinical ethics committees? J Med Ethics 1997; 23:245-249. This article evaluates the need for clinical ethics consultation at two major London children's hospitals, in dealing with questions including children's consent to and refusal of treatment. Because clinical ethics committees exist in so few UK hospitals, in contradistinction to the US, the authors' soundings among clinicians are useful, although the consensus was that such a committee should not try to decide individual cases. Practice is divided among the few UK clinical ethic committees on this issue: the John Radcliffe Hospital Committee in Oxford no longer considers individual cases; whereas, for example, the newly established one at St Mary's Hospital, London, does indeed do so.