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 11 things we know after the Brexit plan debate

Labour may just have fallen into a trap. 

On Wednesday, both Labour and Tory MPs filed out of the Commons together to back a motion calling on the Prime Minister to commit to publish the government’s Brexit plan before Article 50 is triggered in March 2017. 

The motion was proposed by Labour, but the government agreed to back it after inserting its own amendment calling on MPs to “respect the wishes of the United Kingdom” and adhere to the original timetable. 

With questions on everything from the customs union to the Northern Irish border, it is clear that the Brexit minister David Davis will have a busy Christmas. Meanwhile, his declared intention to stay schtum about the meat of Brexit negotiations for now means the nation has been hanging off every titbit of news, including a snapped memo reading “have cake and eat it”. 

So, with confusion abounding, here is what we know from the Brexit plan debate: 

1. The government will set out a Brexit plan before triggering Article 50

The Brexit minister David Davis said that Parliament will get to hear the government’s “strategic plans” ahead of triggering Article 50, but that this will not include anything that will “jeopardise our negotiating position”. 

While this is something of a victory for the Remain MPs and the Opposition, the devil is in the detail. For example, this could still mean anything from a white paper to a brief description released days before the March deadline.

2. Parliament will get a say on converting EU law into UK law

Davis repeated that the Great Repeal Bill, which scraps the European Communities Act 1972, will be presented to the Commons during the two-year period following Article 50.

He said: “After that there will be a series of consequential legislative measures, some primary, some secondary, and on every measure the House will have a vote and say.”

In other words, MPs will get to debate how existing EU law is converted to UK law. But, crucially, that isn’t the same as getting to debate the trade negotiations. And the crucial trade-off between access to the single market versus freedom of movement is likely to be decided there. 

3. Parliament is almost sure to get a final vote on the Brexit deal

The European Parliament is expected to vote on the final Brexit deal, which means the government accepts it also needs parliamentary approval. Davis said: “It is inconceivable to me that if the European Parliament has a vote, this House does not.”

Davis also pledged to keep MPs as well-informed as MEPs will be.

However, as shadow Brexit secretary Keir Starmer pointed out to The New Statesman, this could still leave MPs facing the choice of passing a Brexit deal they disagree with or plunging into a post-EU abyss. 

4. The government still plans to trigger Article 50 in March

With German and French elections planned for 2017, Labour MP Geraint Davies asked if there was any point triggering Article 50 before the autumn. 

But Davis said there were 15 elections scheduled during the negotiation process, so such kind of delay was “simply not possible”. 

5. Themed debates are a clue to Brexit priorities

One way to get a measure of the government’s priorities is the themed debates it is holding on various areas covered by EU law, including two already held on workers’ rights and transport.  

Davis mentioned themed debates as a key way his department would be held to account. 

It's not exactly disclosure, but it is one step better than relying on a camera man papping advisers as they walk into No.10 with their notes on show. 

6. The immigration policy is likely to focus on unskilled migrants

At the Tory party conference, Theresa May hinted at a draconian immigration policy that had little time for “citizens of the world”, while Davis said the “clear message” from the Brexit vote was “control immigration”.

He struck a softer tone in the debate, saying: “Free movement of people cannot continue as it is now, but this will not mean pulling up the drawbridge.”

The government would try to win “the global battle for talent”, he added. If the government intends to stick to its migration target and, as this suggests, will keep the criteria for skilled immigrants flexible, the main target for a clampdown is clearly unskilled labour.  

7. The government is still trying to stay in the customs union

Pressed about the customs union by Anna Soubry, the outspoken Tory backbencher, Davis said the government is looking at “several options”. This includes Norway, which is in the single market but not the customs union, and Switzerland, which is in neither but has a customs agreement. 

(For what it's worth, the EU describes this as "a series of bilateral agreements where Switzerland has agreed to take on certain aspects of EU legislation in exchange for accessing the EU's single market". It also notes that Swiss exports to the EU are focused on a few sectors, like chemicals, machinery and, yes, watches.)

8. The government wants the status quo on security

Davis said that on security and law enforcement “our aim is to preserve the current relationship as best we can”. 

He said there is a “clear mutual interest in continued co-operation” and signalled a willingness for the UK to pitch in to ensure Europe is secure across borders. 

One of the big tests for this commitment will be if the government opts into Europol legislation which comes into force next year.

9. The Chancellor is wooing industries

Robin Walker, the under-secretary for Brexit, said Philip Hammond and Brexit ministers were meeting organisations in the City, and had also met representatives from the aerospace, energy, farming, chemicals, car manufacturing and tourism industries. 

However, Labour has already attacked the government for playing favourites with its secretive Nissan deal. Brexit ministers have a fine line to walk between diplomacy and what looks like a bribe. 

10. Devolved administrations are causing trouble

A meeting with leaders of Scotland, Wales and Northern Ireland ended badly, with the First Minister of Scotland Nicola Sturgeon publicly declaring it “deeply frustrating”. The Scottish government has since ramped up its attempts to block Brexit in the courts. 

Walker took a more conciliatory tone, saying that the PM was “committed to full engagement with the devolved administrations” and said he undertook the task of “listening to the concerns” of their representatives. 

11. Remain MPs may have just voted for a trap

Those MPs backing Remain were divided on whether to back the debate with the government’s amendment, with the Green co-leader Caroline Lucas calling it “the Tories’ trap”.

She argued that it meant signing up to invoking Article 50 by March, and imposing a “tight timetable” and “arbitrary deadline”, all for a vaguely-worded Brexit plan. In the end, Lucas was one of the Remainers who voted against the motion, along with the SNP. 

George agrees – you can read his analysis of the Brexit trap here

Julia Rampen is the editor of The Staggers, The New Statesman's online rolling politics blog. She was previously deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines.