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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It's easy to see where Berlin is being rebuilt – just hit the streets

My week, from walking the streets of Berlin to class snobbery and the right kind of gentrification.

Brick by brick, block by block, the people are rebuilding the city once called Faust’s Metropolis. To see it clearly, put your boots on. One of the most bracing walks starts by the Gethsemane Church, which served as a haven for dissenters in the last days of the GDR and takes you down ­towards the Hackescher Markt.

Here, in what is still the eastern half of a divided city that wears its division more lightly, is a Berlin experience both old and new. In three decades of frequent visits, it has been fascinating to note how much this part of town has changed. Even a decade ago these streets were rundown. With crumbling buildings showing bulletholes, it wasn’t hard to imagine what the place looked like in 1945. Now there are lilacs, blues, and yellows. Cafés, bars and restaurants abound, serving the young professionals attracted to the city by cheap rents and a renewed sense of community.

 

Breaking the fourth wall

Looking north along Schliemannstraße, you’ll find a delightful vista of well-tended balconies. It’s a pleasant place to live, notwithstanding the gaggle of grotesques who gather round the corner in the square. On Kastanienallee, which forms the second leg of the walk, an old city feels young. It’s a kind of gentrification but the right kind. There’s more to eat, to drink, to buy, for all.

Berlin, where Bertolt Brecht staged his unwatchable plays, was supposed to have been transformed by a proletarian revolution. Instead, it has been restored to health by a very middle-class one. Germany has always had a well-educated middle class, and the nation’s restoration would have impossible without such people. The irony is delicious – not that irony buttered many parsnips for “dirty Bertie”.

 

The new snobbery

The British Museum’s survey of German history “Memories of a Nation” is being presented at the Martin-Gropius-Bau as “The British View”. Germans, natürlich, are curious to see how we observe them. But how do they see us?

A German friend recently in England  said that the images that struck him most forcibly were the tins of food and cheap booze people piled up in supermarkets, and the number of teenage girls pushing prams. Perhaps Neil MacGregor, the former director of the British Museum who will shortly take up a similar role here at the new Humboldt Forum, may turn his attention to a “German View” of the United Kingdom.

There’s no shortage of material. In Schlawinchen, a bar that typifies Kreuzberg’s hobohemia, a college-educated English girl was trying to explain northern England to an American she had just met. Speaking in an ugly modern Mancunian voice that can only be acquired through years of practice (sugar pronounced as “sug-oar”), she refer­red to Durham and York as “middle class, you know, posh”, because those cities had magnificent cathedrals.

When it comes to inverted snobbery, no nation can match us. To be middle class in Germany is an indication of civic value. In modern England, it can mark you as a leper.

 

Culture vultures

The Humboldt Forum, taking shape by the banks of the Spree, reconsecrates the former site of the GDR’s Palace of the Republic. When it opens in 2018 it will be a “living exhibition”, dedicated to all the cultures of the world. Alexander von Humboldt, the naturalist and explorer, was the brother of Wilhelm, the diplomat and philosopher, whose name lives on in the nearby university.

In Potsdamerplatz there are plans to build a modern art museum, crammed in between the Neue Nationalgalerie and the Philharmonie, home to the Berlin Philharmonic. Meanwhile, the overhaul of the Deutsche Staatsoper, where Daniel Barenboim is music director for life, is likely to be completed, fingers crossed, next autumn.

Culture everywhere! Or perhaps that should be Kultur, which has a slightly different meaning in Germany. They take these things more seriously, and there is no hint of bogus populism. In London, plans for a new concert hall have been shelved. Sir Peter Hall’s words remain true: “England is a philistine country that loves the arts.”

 

European neighbours

When Germans speak of freedom, wrote A J P Taylor, a historian who seems to have fallen from favour, they mean the freedom to be German. No longer. When modern Germans speak of freedom, they observe it through the filter of the European Union.

But nation states are shaped by different forces. “We are educated to be obedient,” a Berlin friend who spent a year at an English school once told me. “You are educated to be independent.” To turn around Taylor’s dictum: when the English speak of freedom,
they mean the freedom to be English.

No matter what you may have heard, the Germans have always admired our independence of spirit. We shall, however, always see “Europe” in different ways. Europe, good: we can all agree on that. The European Union, not so good. It doesn’t mean we have to fall out, and the Germans are good friends to have.

 

Hook, line and sinker

There are fine walks to be had in the west, too. In Charlottenburg, the Kensington of Berlin, the mood is gentler, yet you can still feel the city humming. Here, there are some classic places to eat and drink – the Literaturhauscafé for breakfast and, for dinner, Marjellchen, a treasure trove of east Prussian forest delights. Anything that can be shot and put in a pot!

For a real Berlin experience, though, head at nightfall for Zwiebelfisch, the great tavern on Savignyplatz, and watch the trains glide by on the other side of Kantstraße. Hartmut Volmerhaus, a most amusing host, has been the guvnor here for more than 30 years and there are no signs that his race is run. The “Fisch” at twilight: there’s nowhere better to feel the pulse of this remarkable city. 

This article first appeared in the 01 December 2016 issue of the New Statesman, Age of outrage