Working with doctors Working for patients

 

Introduction

Christopher is five years old. His mother is concerned that he is being bullied about his ears sticking out, and would like them to be pinned back. Christopher's parents are divorced.

Mrs Rees has brought Christopher to their GP surgery. She wants a hospital referral for Christopher to have an operation to have his ears pinned back.

Mrs Rees

Mrs Rees

I'm sure he's being bullied. Children can be so cruel about things like this and the things they say are really upsetting him. I don't like seeing him so upset.

Dr Williams

Dr Williams

And how does Christopher feel about this?

Mrs Rees

Mrs Rees

How do you think he feels? He hates his ears, and is being picked on. His Dad doesn't want to know. We really need this referral.

What should the doctor do...? (Select A,B or C)

A

Refuse to refer Christopher on the grounds that, as there is no direct therapeutic benefit to the surgery, it would be unlawful and unethical to perform the operation?

B

Agree to refer Christopher to a surgeon for assessment?

C

Tell Mrs Rees that before she makes a referral she would like to speak to Christopher and his father about it to see how they feel?

Dr Williams

See what the doctor did

Dr Williams speaks to Christopher about his ears. Christopher says he is being teased a lot at school which upsets him. Although Mrs Rees is unhappy about it, Dr Williams tries to contact Christopher's father on two occasions, but isn't able to speak to him. In light of her discussions with Christopher and his mother, Dr Williams decides she will refer Christopher to a paediatric surgeon.

References

Doctors should always act in the best interests of children and young people. This should be the guiding principle in all decisions which may affect them. But identifying their best interests is not always easy. This is particularly the case in relation to treatment that does not have proven health benefits or when competent young people refuse treatment that is clearly in their medical interests. There can also be a conflict between child protection and confidentiality, both of which are vitally important to the welfare of children and young people.
(0-18 years: guidance for all doctors, paragraph 8)

An assessment of best interests will include what is clinically indicated in a particular case. You should also consider:
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 parents2
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
(0-18 years: guidance for all doctors, paragraph 12)

You should talk directly and listen to children and young people who are able to take part in discussions about their care. Young people who are able to understand what is being said and who can speak for themselves resent being spoken about when they are present. But younger children might not be able to understand what their illness or proposed treatment is likely to involve, even when explained in straightforward terms.
(0-18 years: guidance for all doctors, paragraph 19)

Both the GMC and the law permit doctors to undertake procedures that do not offer immediate or obvious therapeutic benefits for children or young people, so long as they are in their best interests and performed with consent.
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. This may be relevant in circumcision of male children for religious or cultural reasons15, or surgical correction of physical characteristics that do not endanger the child's life or health.
(0-18 years: guidance for all doctors, paragraphs 34-35)

If providing treatment to children, you should be familiar with the detailed advice in 0-18 years: guidance for all doctors, which includes the key points set out in this section of guidance. You should take particular care if you consider providing cosmetic interventions for children or young people - you should make sure the environment for practice is appropriate to paediatric care, and work with multidisciplinary teams that provide expertise in treating children and young people where necessary.
(Cosmetic interventions, paragraph 32)

You must only provide interventions that are in the best interests of the child or young person. If a young person has capacity to decide whether to undergo an intervention, you should still encourage them to involve their parents in making their decision.
(Cosmetic interventions, paragraph 33)

A parent can consent to an intervention for a child or young person who does not have the maturity and capacity to make the decision, but you should involve the child in the decision as much as possible. If you judge that the child does not want to have the cosmetic intervention, then you must not perform it.
(Cosmetic interventions, paragraph 34)