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?

Grant Shapps on the campaign trail. Photo: Getty
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Grant Shapps resigns over Tory youth wing bullying scandal

The minister, formerly party chairman, has resigned over allegations of bullying and blackmail made against a Tory activist. 

Grant Shapps, who was a key figure in the Tory general election campaign, has resigned following allegations about a bullying scandal among Conservative activists.

Shapps was formerly party chairman, but was demoted to international development minister after May. His formal statement is expected shortly.

The resignation follows lurid claims about bullying and blackmail among Tory activists. One, Mark Clarke, has been accused of putting pressure on a fellow activist who complained about his behaviour to withdraw the allegation. The complainant, Elliot Johnson, later killed himself.

The junior Treasury minister Robert Halfon also revealed that he had an affair with a young activist after being warned that Clarke planned to blackmail him over the relationship. Former Tory chair Sayeedi Warsi says that she was targeted by Clarke on Twitter, where he tried to portray her as an anti-semite. 

Shapps appointed Mark Clarke to run RoadTrip 2015, where young Tory activists toured key marginals on a bus before the general election. 

Today, the Guardian published an emotional interview with the parents of 21-year-old Elliot Johnson, the activist who killed himself, in which they called for Shapps to consider his position. Ray Johnson also spoke to BBC's Newsnight:


The Johnson family claimed that Shapps and co-chair Andrew Feldman had failed to act on complaints made against Clarke. Feldman says he did not hear of the bullying claims until August. 

Asked about the case at a conference in Malta, David Cameron pointedly refused to offer Shapps his full backing, saying a statement would be released. “I think it is important that on the tragic case that took place that the coroner’s inquiry is allowed to proceed properly," he added. “I feel deeply for his parents, It is an appalling loss to suffer and that is why it is so important there is a proper coroner’s inquiry. In terms of what the Conservative party should do, there should be and there is a proper inquiry that asks all the questions as people come forward. That will take place. It is a tragic loss of a talented young life and it is not something any parent should go through and I feel for them deeply.” 

Mark Clarke denies any wrongdoing.

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.