Dr Hajra Siraj, GP registrar in London, shares a tricky case around assessing the competence of young people
Miss F was a 15-year-old schoolgirl from a devout Christian household. She had started dating a boy in her class, aged 16, and had recently become sexually active. They were not using any form of contraception, and after missing her last period, Miss F rightly suspected that she may be pregnant. This was confirmed with a positive home pregnancy test.
Anxious and distressed, Miss F was not sure what to do. She was uncertain of who to confide in, so came to me, as her medical practitioner, for advice and guidance. During the consultation, we formally repeated the test, and estimated she was roughly six weeks into her pregnancy. She was asymptomatic, other than some mild morning nausea.
Having confirmed the sexual activity was fully consensual and without coercion, we delved deeper into her dilemma. Miss F wanted to know what her options were in terms of the pregnancy. I explained there were three main routes she could take: to continue with the pregnancy and raise the child, to offer the baby for adoption, or to terminate the pregnancy. She fully understood the alternatives available, and that ultimately the decision would lie with her.
In addition, I highlighted the importance of attending a sexual health clinic for a full sexually-transmitted infection screen, and for advice about contraception in the future. I assessed Miss F during the consultation, and considered her to be competent to make her own decision. As a mature 15-year-old, she understood the options that were given to her, and was able to weigh up the benefits and drawbacks of each.
I highlighted to Miss F the importance of involving her family in her pregnancy, for further advice and support at home. I offered her a follow-up appointment in two days’ time, which she agreed to attend with one of her parents. Miss F did not attend her follow-up consultation as planned, and I was unable to get in touch with her despite multiple attempts calling her mobile phone, as well as sending a letter.
"Miss F did not attend her follow-up consultation as planned, and I was unable to get in touch with her despite multiple attempts calling her mobile phone, as well as sending a letter."
Two weeks later, her father, Mr F, booked an appointment with me. He had with him a discharge letter from the local hospital stating that Miss F had been admitted, only a few days after our initial consultation. Presenting with a ruptured ectopic pregnancy, she required an emergency laparotomy as a life-saving procedure, and a two-unit blood transfusion.
She spent over a week in hospital recovering, physically and emotionally. Mr F was unaware of his daughter’s situation until her emergency hospital admission. Although he understood the ectopic presentation could not have been anticipated, he was angry that her GP did not inform him immediately, when the pregnancy was initially confirmed. He adamantly believed that his daughter should not be making life-changing decisions at the age of 15 years, without parental consent. Mr F was keen to take the issue further, and make a formal complaint.
As doctors we are taught to respect and value the patient’s right to confidentiality. However, in cases involving minors, it is often difficult to balance this with a parent’s unwritten right to know what’s going on with their child. Parents want, and often instinctively know, what’s best for their children – is it right for us, as medical practitioners, to deny them this information?
MPS Advice By Dr Gordon McDavid
This difficult scenario highlights many ethical issues that would require any doctor to take a moment to consider their professional obligations. In a case like this I would strongly recommend involving a senior clinician or seeking advice from MPS.
It may be helpful to tackle the issues in two stages: firstly Dr Siraj’s consultation with Miss F and thereafter how to approach the consultation with Miss F’s father.
Initial contact with Miss F
The age of majority differs even between jurisdictions in the UK and it is widely accepted that the law pertaining to children and young people is complex. The GMC’s consent guidance provides helpful information (see par 55).
Doctors are encouraged to assess maturity on a case-by-case basis. This guidance flows from recognition of variation in maturity between individuals and although age is a consideration, this should not be relied upon in isolation.
Miss F is 15-years-old and Dr Siraj considers she has reached sufficient maturity to understand her pregnancy and also the options available to her. As Miss F is able to understand and retain the information allowing her to weigh up the options to then reach an informed decision, she would be considered competent.
"As Miss F is able to understand and retain the information allowing her to weigh up the options to then reach an informed decision, she would be considered competent."
There are clear benefits to involving a young person’s parents in important decisions; however if a competent young person does not wish their parents to be involved, this should usually be respected. This may differ in cases of life sustaining treatment, or when it is in the child’s best interest to involve their parents. Very young children need their parents, or those with parental responsibility, to make decisions on their behalf but as children mature, their ability to be involved in decisions gradually increases until reaching an age of sufficient maturity to be considered competent.
It would appear Dr Siraj has carefully navigated this challenging consultation, adopting a patient-focused strategy and leaving Miss F with information to enable her to reach a decision about her future. Miss F has capacity to make decisions regarding her pregnancy meaning her wishes should be honoured (as long as they are in her interests) without neccessarily needing her parents’ consent.
Contact with Miss F’s father
It is very unfortunate that Miss F endured these life-threatening complications and her father’s reaction is not unexpected. He insists that he should have been informed of the pregnancy. It is important to remember that doctors have the same duty of confidentiality to children and young people as they do to adults.
"It is important to remember that doctors have the same duty of confidentiality to children and young people as they do to adults."
However, in very young children who have not reached sufficient maturity to make a decision on their own, information can be shared with parents as they are required to make decisions on their child’s behalf. Older children may agree to involving their parents; however if this is not the case, careful consideration is required. In this case, it would appear that Miss F was planning to involve the parents; however complications overtook this.
Faced with Miss F’s irate father, it would be advisable for Dr Siraj to listen to and record his concerns, but to decline to impart any of Miss F’s confidential information until such time as she has had opportunity to speak with Miss F and seek her consent to sharing this information.
A possible strategy may be to agree to consult with Miss F when she is well enough and, provided she agrees, to arrange a consultation together with her parents to discuss these matters in detail. While it is helpful to encourage a child or young person to share information with their parents, doctors should not go against the wishes of a competent young person, unless there are exceptional circumstances justifying this.
Dr Siraj did not have Miss F’s consent to tell her parents about the pregnancy. This may be difficult for Mr F to accept; however Dr Siraj owed Miss F a duty of confidentiality and it is for Miss F to decide who to share this information with. It is vital to ensure Miss F’s welfare and as indicated above, such a situation would warrant involvement of a senior clinician and/or seeking advice from MPS.
GMC consent guidance (Par 55)
“A young person’s ability to make decisions depends more on their ability to understand and weigh up options, than on their age. When assessing a young person’s capacity to make decisions, you should bear in mind that:
(a) a young person under 16 may have capacity to make decisions, depending on their maturity and ability to understand what is involved
(b) at 16 a young person can be presumed to have capacity to make most decisions about their treatment and care.”