Childhood Mental Illness and Consent to Admission and Treatment

BRITISHJOURNAL OF PSYCHIATRY 2001), 179, 384^386 EDITORIAL Feeling the way: childhood mental illness recommendation of the expert Mental Health Act Review Committee that the and consent to admission and treatment age for capacity to make treatment decisions be lowered to 16, with a presump- tion of competence from the age of 10 to 12 TAMSIN FORD and ANTONY KESSEL years Department of Health, 1999). According to the Mental Health Act 19831983 Code of Practice, parental authority is sufficient for the detention and treatment of any minor regardless of competence Department of Health & Welsh Office, 1999). Few child psychiatrists would be With the enactment of the Human Rights mid-20th century Faden & Beauchamp, willing to use parental authority alone to Act 1998 and with the prospect of new 1986). The Nuremberg Code 1947, together override the wishes of a competent 16-year- mental health legislation, formal admission with the World Medical Association old, suggesting that this advice conflicts and compulsory treatment are topical issues Declaration of Helsinki 1964, also increased with current clinical practice as well as Department of Health, 1999). Discussions the focus on patient autonomy, especially human rights theory Shaw, 1999). rarely centre on children, probably as pertaining to medical research Faden & Case law distinguishes between consent admissions for severe mental illness are un- Beauchamp, 1986). Legal opinion predicts and refusal of treatment Dickenson, 1994). common in this age group, and are scattered that the Human Rights Act 1998 will lead Lord Scarman's ruling that: among specialist adolescent units, secure to an increase in the amount of in- social service facilities and adult psychiatric forformationmation that doctors are expected to ``the parental right to determine whether their child below the age of16of 16 will have medical treat- wards. The question of whether a com- provide for their patients and a correspond- ment terminates if and when the child achieves a petent child's human rights are infringed ingly stronger emphasis on patient self- sufficientunderstandingandintelligence to enable by overriding their autonomy requires care- determinism Hewson, 2000). Adolescents themto understand fully whatisproposed'' ful thought by mental health professionals, will be able to demand greater autonomy, regardless of how often they encounter but whether this will reverse the trend of gave rise to the term `Gillick competent' young people. Ultimately the ethical and recent case law towards greater paternalism GillickGillick v.v. West Norfolk and Wisbech Area legal framework developed from extreme is difficult to predict. Health Authority, 1986). cases influences daily clinical practice. To However, in the case of R, a 15-year- stimulate debate, we summarise the history old ward of court admitted for assessment and legal framework of consent, and LEGAL FRAMEWORK of a suspected psychotic illness, who re- discuss the developmental issues affecting fused medication, the Appeal Court judged capacity, and the ethical and clinical The United Nations Convention on the that a child with a fluctuating mental capa- implications in relation to children with Rights of the Child, ratified by Britain in city could never be considered competent, psychiatric disorder. 1991, states that children have the same even when lucid Re: R A minor) Ward- inherent dignity and equal rights as adults ship: Medical Treatment) 1991). In a sub- do, but also recognises that children are sequent case involving W, a 16-year-old HISTORY OF CONSENT born dependent and have a right to pro- girl with anorexia nervosa, the Appeal tection and guidance. Court heldCourtheldthat the Family Law Reform Although conceived by clinicians as a English statute, although not as unequi- Act 1969 hadnot removed a parent's right medico-legal requirement Kessel, 1994), vocal as the United Nations Convention, to consent on their child's behalf Re: W consent has a moral foundation expressed endorses a limited degree of autonomy for A minor) Wardship: Medical Treatment), in the ethical principle of respect for children. The Family Law Reform Act 1992).1992). autonomy, which is enshrined by Article 5 19691969empoweredempowered 16- and 17-year-olds to In contrast, competent adults can refuse the right to liberty) and Article 8 the right consentconsentto medical interventions in the same any medical intervention for reasons that to privacy) of the Human Rights Act 1998. manner as adults Kennedy & Grubb, are ``rational or irrational or for no reason'' Although the right to information was 1994). TheChildren Act 1989 weighed SidawaySidaway v.v. Governors of Bethlem Royal acknowledged by Percival as early as the the principle that children's wishes should Hospital, 1985). Equally, adults detained 19th century, it was also seen as potentially be sought and respected whenever possible under the Mental Health Act 1983 are not harmful, and he recommended benevolent against professional's perceptions of the necessarily incompetent with regard to all deception Faden & Beauchamp, 1986). Such child's best interests, and granted limited treatment decisions. The case of C, a patient beneficence dominated physicians' attitudes rights to refuse medical examination and at Broadmoor with schizophrenia who to information-sharing for centuries, and treatmenttreatmenttoto children looked after by the refused the amputation of his gangrenous given the recent events at Alder Hey local authorityKennedy & Grubb, 1994). foot, led to a legal test of competence in Hospital, some would argue still does. The application of the Mental Health adults; namely the comprehension and The concept of informed consent in Act 1983 is the same regardless of age retention of relevant information, believing relation to patient autonomy developed and there is no lower age threshold. Sadly, it and weighing it up in order to reach a from legal cases concerning battery and it seems that the Government of England decision Re: C Adult: Refusal of treatment), negligence brought against doctors in the and Wales is unlikely to accept the 1994).1994). 384 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 20:11:23, subject to the Cambridge Core terms of use. CHILDREN AND CONSENT TO ADMISSION AND TREATMENT In summary, English law affords minors When hypothetical situations were respect for autonomy, beneficence and the the right to consent to, but not to refuse, explained to healthy volunteers, 9- and fiduciary principle. Whereas the balance has medical treatment, which suggests a right 14-year-olds made decisions comparable been firmly tipped towards autonomy for to agree with your doctors Dickenson, to those of adults, although the younger adults with psychiatric illness, for children 1994). However, the decision to refuse group showed less understanding and used the major influence remains their welfare medical treatment can have grave con- concrete rather than abstract reasoning as perceived by clinicians and those with sequences, and our society is driven Weithorn & Campbell, 1982). As children parental responsibility. towards the preservation of life. In the past make similar choices to those of adults and, Although there is a real risk of bur- the needtheneedfor a higher level of understanding by the age of 14, base them on similar rea- dening immature children while relieving if treatment was refused was justified as soning to that of adults, it seems illogical to parents and professionals) from their duty refusal questions expert opinion and doctors treat them differently. to guide and protect, children are maturing were expected to act in their patients' best The legal definition of capacity empha- earlier and, as most psychiatric disorders interest Batten, 1996). sises rationality, but this is not the only are chronic, children and families are facing This assumption is debatable in the determinant of our ability to make decisions. choices about the quality of life rather, than light of recent medical scandals, as is the Other attributes, such as emotion, experi- life or death Dickenson, 1994). As the similar assumption that parents inevitably ence, preference and social context, contri- nature of the choices and the develop- act with their child's welfare in mind, parti- bute to decision-making Dickenson, 1994; mental level of those faced with them cularly for those working in child protection Rushforth, 1999). From her study of 120 changes, we should increasingly trust the scenarios Batten, 1996). Paradoxically, the children undergoing orthopaedic surgery, autonomy of the youngsters who will have legal system is unwilling to accept the Alderson contrasts child factors such as to live with their impact. right of a 17-year-old to determine what temperament, understanding, intelligence An additional tension exists between happens to his or her body, when the age and independence) with parental influence respect for emerging autonomy and the of criminal responsibility now stands at 10 and the approach of the medical team, avoidance of harm; psychological or physical years Dickenson, 1994). If parents and who are in turn constrained by the legal impairment may result if the child does not the courts can overrule competent minors, and ethical framework in which they work receive treatment Batten, 1996). Overruling children are not being granted the ``equal Alderson, 1993). a youngster may seem wrong in terms of and inalienable'' rights afforded them by Parental expectations can mould the denying his

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