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?

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The murder of fearless journalist Pavel Sheremet must be solved - but Ukraine needs more

Sheremet was blown up as he drove to host a morning radio programme

On 20th of July Kiev was shaken by the news of the assassination of the respected Belarusian journalist Pavel Sheremet. Outside the ex-Soviet republics he was hardly known. Yet the murder is one that the West should reflect on, as it could do much to aggravate the Ukrainian-Russian conflict. 

Sheremet was one of the most significant and high profile investigative journalists of his generation. His career as an archetypal  examiner of the post-Soviet regimes in Belarus, Ukraine and Russia bought him fame and notoriety in the region. From 1997 onwards Sheremet became a name for fearless and non-partisan interrogation, both in print and as also as TV presenter. He paid the price early on when he was incarcerated by the Belarus government, then stripped of his Belarusian nationality and deported. Such is the way of things in the region.

Taking up residence in Kiev, Sheremet became immersed in interrogating the political life of Ukraine. He wrote for the Ukrayinska Pravda publication and also helped to develop a journalism school. Under these auspices he was a participant of a congress, "The dialogue between Ukraine and Russia", in April 2014. He reported on beginnings of the Euromaidan uprising. He warned of the rise of the concept  of "Novorossia" and suggested that Ukraine needed to reset its current status and stand up to Russian pressure. After the Russian occupation of Crimea his blame for the Ukrainian government was ferocious. He alleged that that they "left their soldiers face to face the [Russian] aggressor and had given up the Crimean peninsula with no attempt to defend it." These, he said "are going to be the most disgraceful pages of Ukrainian history."

Sheremet was blown up at 7.45am on 20 July as he drove to host a morning radio programme.

Ukraine is a dangerous place for journalists. Fifty of them have been murdered since Ukraine achieved independence. However, this murder is different from the others. Firstly, both the Ukrainian President and the Interior minister immediately sought assistance from FBI and EU investigators. For once it seems that the Ukrainian government is serious about solving this crime. Secondly, this IED type assassination had all the trappings of a professional operation. To blow a car up in rush hour Kiev needs a surveillance team and sophisticated explosive expertise. 

Where to lay the blame? Pavel Sheremet had plenty of enemies, including those in power in Belarus, Russia and the militias in Ukraine (his last blog warned of a possible coup by the militias). But Ukraine needs assistance beyond investigators from the FBI and the EU. It needs more financial help to support credible investigative journalism.   

The murder of Pavel Sheremet was an attack on the already fragile Ukrainian civil society, a country on the doorstep of the EU. The fear is that the latest murder might well be the beginning of worse to come.

Mohammad Zahoor is the publisher of Ukrainian newspaper The Kyiv Post.