Antidepressants fluoxetine photographed in the US. Photo: Getty Images.
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When are we mature enough to make life-or-death decisions about our body?

This 16-to-17 age band can pose the most acute ethical dilemmas, as a case in my area illustrated all too starkly.

It is straightforward to provide medical care to a child of, say, four. You seek consent from a parent and usually they grant it; then, you roll up your sleeves and do what is necessary, insulating yourself the best you can from any howls of protest from the patient. Yet fast-forward ten years to when your patient has reached the foothills of adulthood and things are more complex.

It was only in 1985 that the right of a child under 16 to consent to medical treatment was legally established. Victoria Gillick, a mother of five girls, sought to prohibit doctors from providing contraception without her knowledge to any of her daughters while they were under 16. The case went to the House of Lords, where Lord Fraser ruled that, providing that a child had sufficient maturity and understanding, they could consent to medical treatment irrespective of age.

Doctors now regularly gauge this understanding and maturity – the so-called Fraser competence of a minor – and, where established, involve them in decisions about their care. While doctors are expected to encourage parental involvement, it need not be insisted on if the child does not wish their parents to be informed.

Parents cannot overrule consent given by a Fraser-competent child. Paradoxically, if a competent minor withholds consent for care that is felt to be in their best interests, a parent or a court can override their decision. Such cases are rare but they illustrate an important point: we are prepared to grant autonomy when our children agree with the prevailing orthodoxy but we are reluctant to allow them the freedom to make perverse decisions. This must have its roots in an appreciation that medical procedures are often scary and, no matter how competent our children appear to be, they may still be too influenced by fear to be allowed free rein.

No such protection applies beyond the age of 18. Once we reach adulthood, we can decide whatever we like, even if refusing consent to treatment will result in our death. Perhaps the most difficult challenge comes when dealing with patients who are 16 or 17. These adolescents are legally presumed, by virtue of their age, to have the capacity to consent. Yet, unlike over-18s, they can still have a refusal to consent overridden by someone with parental authority or by a court. This 16-to-17 age band can pose the most acute dilemmas, as a case in my area illustrated all too starkly.

The patient was a youth we’ll call Ross, whose mood had been low for some time, probably as a result of bullying. Eventually, his parents persuaded him to see his GP and accompanied him to the surgery. However, Ross wanted to consult with the doctor by himself and his parents, respecting his nascent autonomy, stayed in the waiting room.

During the consultation, it became clear that Ross was severely depressed and he confessed to the doctor something that no one, not even his parents, knew: he had recently tried to commit suicide. The GP recognised that the attempt had been no mere “cry for help” and made an urgent referral to the Child and Adolescent Mental Health Services (CAMHS).

Contact should have been made the following day but because of a transcription error, the wrong mobile number was given and Ross never received the promised call. Instead, a computer-generated letter giving details of an appointment was sent out, which Ross subsequently opened. He never attended. Before the appointment date, his body was found hanging in his bedroom by his mother.

One focus at the inquest was the GP’s decision not to breach Ross’s confidentiality and inform his parents of the depth of his depression and his suicide risk. Had they been made aware, his parents said, they would have ensured that someone was with him constantly. They were also ignorant of the details of the proposed CAMHS involvement, so they had no idea that an attempt to reach him by a phone had failed. When Ross’s appointment letter was looked at after his death, it was found to be formal and stark – a style that parents would be familiar with but was inappropriate for an emotionally vulnerable youth.

Lessons have been learned about reducing the potential for errors in the urgent referral process and about having more adolescent-friendly stationery and letter content. Many people will also have sympathy for Ross’s parents’ impassioned plea that it should be made mandatory for a 16- or 17-year-old’s parents to be informed in these cases, irrespective of the child’s wish for confidentiality. They believe an adolescent with significant depression is a special case in which only qualified autonomy is appropriate.

Set against this is the reality that mental health issues affect around 15 per cent of children and adolescents and, in many cases (though not in Ross’s), family dysfunction, sometimes even abuse, is the underlying problem – a problem that might only become apparent with time and trust. To force doctors to breach confidentiality in those circumstances could have its own equally disastrous consequences.

This article first appeared in the 13 February 2014 issue of the New Statesman, Can we talk about climate change now?

Photo: Dan Kitwood/Getty Images
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Conservative disunity is not all good news for Labour

The Tory leadership election could squeeze Labour out of the conversation, just like Blair and Brown did to the Tories.

The first test of opposition politics is relevance. Other key yardsticks - political plausibility, economic credibility, setting the agenda and developing a governing vision - all matter greatly. But making yourself a central part of the relentless cycle of daily politics, the terms of which are generally set by the governing party, is the first hurdle. It matters not whether you sign up to new politics or old: be relevant or wither. 

The issue of relevance is becoming a pressing issue for Labour. Take George Osborne’s favoured issue of the so-called national living wage.  Leave to one side the rights, wrongs and nuances of the policy and just consider the basic political dynamic it creates.  Osborne has, quite deliberately, set up a rolling five year argument over a steadily rising wage floor. On one side, is the Chancellor arguing that his policy is the right thing for Britain’s ranks of low paid workers. Pitted against him are ranks of chief executives of low-paying big business. With each impending hike they will holler at Osborne to go no further and the media will happily amplify the row. In response the Chancellor will quietly smile.

Sure, on occasions this will be uncomfortable stance for Mr Osborne (and if the economy takes a downward turn then his pledge will become incredible; there are always big risks with bold strokes).  Yet the dominant argument between the Conservatives and big business leaves Labour largely voiceless on an issue which for generations it has viewed as its own.

We may well see a similar dynamic in relation to the new national infrastructure commission – another idea that Osborne has plundered form Labour’s 2015 manifesto. It’s far too early to say what will come of its work looking at proposals for major new transport and energy projects (though those asserting it will just be a talking shop would do well not to under-estimate Andrew Adonis, its first Chair). But there is one thing we can already be confident about: the waves of argument it will generate between Osborne’s activist commissioners and various voices of conservatism. Every big infrastructure proposal will have noisy opponents, many residing on the right of British politics. On the issue of the future of the nation’s infrastructure – another touchstone theme for Labour – the opposition may struggle to get heard amid the din.

Or take the different and, for the government, highly exposing issue of cuts to tax credits. Here the emerging shape of the debate is between Osborne on one side and the Sun, Boris Johnson, various independent minded Conservative voices and economic think-tanks on the other. Labour will, of course, repeatedly and passionately condemn these cuts. But so have plenty of others and, for now at least, they are more colourful or credible (or both).  

The risk for the opposition is that a new rhythm of politics is established. Where the ideological undercurrent of the government steers it too far right, other voices not least those within the Conservative family - moderates and free-spirits emboldened by Labour’s current weakness; those with an eye on the forthcoming Tory leadership contest – get reported.  Where Osborne consciously decides to tack to the centre, the resulting rows will be between him and the generally Conservative supporting interests he upsets. Meanwhile, Labour is left struggling for air.

None of which is to say there are no paths back to relevance. There are all sorts of charges against the current government that, on the right issues, could be deployed - incompetence, complacency, inequity – by an effective opposition.  Nor is the elixir of relevance for a new opposition hard to divine: a distinct but plausible critique, forensic and timely research, and a credible and clear voice to deliver the message. But as yet we haven’t heard much of it.

Even in the best of times being in opposition is an enervating existence. Those out of power rarely get to set the terms of trade, even if they often like to tell themselves they can. Under Ed Miliband Labour had to strain – sometimes taking big risks - to establish its relevance in a novel era defined by the shifting dynamics of coalition politics. This time around Jeremy Corbyn’s Labour is up against a Chancellor willing to take risks and pick big fights: often with traditional Tory foes such as welfare claimants; but sometimes with people on his own side.  It’s also a new and challenging context. And one which Labour urgently needs to come to terms with.   

Gavin Kelly is chief executive of the Resolution Foundation