GPs frequently see patients who are aged under 18 years of age without the parents being present. If the GP decides to treat these patients without parental knowledge or consent parents may complain about the doctor’s actions. It is thus essential that all GPs understand the rules and guidelines which pertain to treating non-adults.
Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions.
"...whether or not a child is capable of giving the necessary consent will depend on the child’s maturity and understanding and the nature of the consent required. The child must be capable of making a reasonable assessment of the advantages and disadvantages of the treatment proposed, so the consent, if given, can be properly and fairly described as true consent." (Gillick v West Norfolk, 1984)
The ability of a child to consent or withhold consent varies with age.
18 year olds and over are judged to be adult, and are thus able to consent to or refuse treatment, unless other factors are present which reduce their capacity to make decisions. 16 and 17 year olds are also able to give consent to treatment or investigation, and parents are unable to override this consent without seeking a court injunction.
Under age 16
Children under age 16 can consent to medical treatment if they understand what is being proposed. It is up to the doctor to decide whether the child has the maturity and intelligence to fully understand the nature of the treatment, the options, the risks involved and the benefits. A child who has such understanding is considered Gillick-Fraser competent. The parents cannot overrule the child’s consent when the child is judged to be Gillick-Fraser competent.
A competent child is legally entitled to withhold consent to treatment. However, if a child or young person is considered to be Gillick-Fraser competent, and the doctor and parents believe that the patient will be harmed by refusing treatment, legal advice from the courts can be sought.
Children under 16 who are not Gillick-Fraser competent cannot either give or withhold consent. Those with parental responsibility need to make the decision on their behalf. It may, however, be better to allow the parents time to discuss this with a child rather than forcing treatment or investigation upon an unwilling patient.
It is also important to understand the child’s reasons for withholding consent. GMC guidance specifically states that-
Effective communication between doctors and children and young people is essential to the pro-vision of good care. You should find out what children, young people and their parents want and need to know, what issues are important to them, and what opinions or fears they have about their health or treatment. In particular you should:
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.
In an emergency, the doctor is able consider what the child’s best interests are and then act appropriately, even if a parent is not available.
Assessing Gillick-Fraser Competence
GPs and nurses seeing patients aged less than 16 should assess their Gillick-Fraser competence before providing treatment, or performing examination or investigations. Gillick-Fraser competence is based upon the rules set out for providing contraception. For a girl to be deemed Gillick-Fraser competent the doctor must be satisfied-
1. that the girl (although under the age of 16 years of age) will understand his/her advice;
2. that he/she cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;
3. that she is very likely to continue having sexual intercourse with or without contraceptive treatment;
4. that unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
that her best interests require him to give her contraceptive advice, treatment or both without the parental con-sent.
These rules can be applied to treating any child who seeks advice about any other medical condition. The person consulting with the child should assess each of these criteria and note in the record for each whether the patient satisfies the criterion and thus whether the patient is Gillick-Fraser competent or not.
It is important to note that whether a child is Gillick-Fraser competent or not, under-age sexual activity should always be considered as a marker of possible child sexual exploitation.
Furthermore, sexual activity with a child under 13 is a criminal offence and should always result in a child protection referral.
NSPCC guidance on Gillick-Fraser competence