0–18 years: guidance for all doctors

Making decisions

22

You can provide medical treatment to a child or young person with their consent if they are competent, or with the consent of a parent or the court.6 You can provide emergency treatment without consent to save the life of, or prevent serious deterioration in the health of, a child or young person.

6

Mental health legislation provides another legal basis for the treatment of children and young people with mental health disorders.

23

You should involve children and young people as much as possible in decisions about their care, even when they are not able to make decisions on their own.

If a young person refuses treatment

30

Respect for young people’s views is important in making decisions about their care. If they refuse treatment, particularly treatment that could save their life or prevent serious deterioration in their health, this presents a challenge that you need to consider carefully.

31

Parents cannot override the competent consent of a young person to treatment that you consider is in their best interests. But you can rely on parental consent when a child lacks the capacity to consent. In Scotland parents cannot authorise treatment a competent young person has refused.13 In England, Wales and Northern Ireland, the law on parents overriding young people’s competent refusal is complex.14 You should seek legal advice if you think treatment is in the best interests of a competent young person who refuses.15 

13

See Houston (applicant) [1996] 32 BMLR 93.

14

See Re R (a minor) [1991] 4 All ER 177.

15

Children Act 1989, Children Act (Northern Ireland) Order 1995 and Children Act (Scotland) 1995 give competent young people statutory rights to refuse medical or psychiatric assessments or examinations directed by the court or a children’s hearing for purposes of an interim care, supervision, child protection or emergency protection order or, in Scotland, a supervision requirement, assessment, protection or place of safety order. A young person’s refusal can be overridden in England, Wales and Northern Ireland by the inherent jurisdiction of the High Court (see South Glamorgan County Council v W & B [1993] 1 FLR 574). The position is less clear in Scotland; see Age of Legal Capacity (Scotland) Act 1991.

32

You must carefully weigh up the harm to the rights of children and young people of overriding their refusal against the benefits of treatment, so that decisions can be taken in their best interests.16 In these circumstances, you should consider involving other members of the multi-disciplinary team, an independent advocate, or a named or designated doctor for child protection. Legal advice may be helpful in deciding whether you should apply to the court to resolve disputes about best interests that cannot be resolved informally.

16

See Re W (A Minor) (Medical Treatment: Court’s Jurisdiction)[1993] Fam 64, [1992] 4 All ER 627 CA.

33

You should also consider involving these same colleagues before seeking legal advice if parents refuse treatment that is clearly in the best interests of a child or young person who lacks capacity, or if both a young person with capacity and their parents refuse such treatment.17 For further guidance on these issues see GMC guidance on consent and treatment and care towards the end of life.

17

See Re P (Medical Treatment: Best Interests) [2004] 2 FLR 1117.

Procedures undertaken mainly for religious, cultural, social or emotional reasons

34

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 (see paragraphs 12 and 13) and performed with consent (see paragraph 27).

12

An assessment of best interests will include what is clinically indicated in a particular case. You should also consider:

  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 parents4 
  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.
13

This list is not exhaustive. The weight you attach to each point will depend on the circumstances, and you should consider any other relevant information. You should not make unjustified assumptions about a child or young person’s best interests based on irrelevant or discriminatory factors, such as their behaviour, appearance or disability.

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.10 

35

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 reasons18, or surgical correction19 of physical characteristics that do not endanger the child’s life or health.

18

See our guidance on Personal beliefs and medical practice; The law and ethics of male circumcision – Guidance for doctors, BMA 2006; Religious circumcision of male children: standards of care, British Association of Paediatric Surgeons (BAPS) 2001, and Statement on Male Circumcision, BAPS, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists, 2001. Female genital mutilation (sometimes referred to as female circumcision) is a serious crime and a child protection issue, whether undertaken in the UK or abroad. Since October 2015 doctors in England and Wales have had a legal duty to report known cases of FGM in girls and young women aged under 18 to the police. HM Government has published two guidance documents on FGM: Multi-agency statutory guidance on female genital mutilation and Mandatory reporting of female genital mutilation: procedural information.

Research

36

Research involving children and young people can benefit all children; but they may be vulnerable because they cannot always recognise their best interests, express their needs or defend their rights.

37

Children or young people should be involved in research only when research on adults cannot provide the same benefits. They can be involved in research that has either:

  1. potential benefits for children or young people generally, as long as the research does not go against their best interests or involves only minimal or low risk of harm (this would be research that involves, for example, asking questions or taking blood samples, the assessment of the risk depending on the view of the child or young person), or
  2. potential therapeutic benefits for them that outweigh any foreseeable risks, which should be kept as low as possible.
38

Children and young people should not usually be involved in research if they object or appear to object in either words or actions, even if their parents consent. If they are able to consent for themselves, you should still consider involving their parents, depending on the nature of the research.20 

20

See the Declaration of Helsinki and Medicines for Human Use (Clinical Trials) Regulations 2004, which requires parental consent to complement even competent under-16s’ agreement to involvement in trials.

39

You must not put pressure on children, young people or their parents to consent to research in the expectation of therapeutic, financial or any other benefit.

40

Before involving children or young people in research21 you should seek advice and get the necessary approval from a relevant research ethics committee, the Medical Research Council22 or a medical royal college.23 

21

See GMC guidance on Good practice in research.

23

See Guidelines for the ethical conduct of medical research involving children, Royal College of Paediatrics and Child Health: Ethics Advisory Committee in Archives of Disease in Childhood, February 2000, Vol 82, No 2, p 177-182.

Donation, transplantation, organ and tissue storage and use

41

The Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006 were passed following inquiries into the storage of children’s organs and tissue without the proper consent.  The Acts make consent central to the lawful storage and use of children and young people’s organs and tissue, and to the removal of such material after death. The Human Tissue Authority regulates and issues codes of practice on activities covered by the Act in England, Wales and Northern Ireland. Scottish ministers have those powers in Scotland.