New guidance published by the General Medical Council (GMC) in the UK this week requires that GPs take young people seriously, involve them in treatment and explain problems to them properly. This, in and of itself, is a positive move. However, as part of the new guidance, are requirements for GPs that state that even when children are under sixteen but not under thirteen, they can be given advice and treatment on contraception, sexually transmitted infections and even abortion without parental knowledge or consent. So is it time that young people even as young as thirteen were given adult rights with regard to medical treatment or are these guidelines a step too far?
Generally, over and above anyone else, parents are meant to look after their children. However, there are families where children and parents do not share good relationships or, even if they do, certain topics may be off limits in the minds of the children. In any case, the GMC is right to promote stronger relationships between doctors and young people. The doctor-patient relationship is vital in the case of any patient because, without it, both trust and treatment could be compromised. In the case of children and young people, involving them in decision-making might be beneficial to their overall health and well-being. They might be more inclined to abide by a course of treatment that they have chosen rather than one that has been chosen for them and that they have been instructed to follow.
If children are competent to make decisions governing their health, there is no moral reason to stop them from doing so. Children, like adults, can differ in their levels of competence. But, as is the case with adults, competence ought to be determined carefully. Broadly, competence ought to entail an understanding of the problem or condition, an understanding of the alternatives available to address the problem and the implications of each of these alternatives. For the purposes of decision-making, the individual ought to also be able to communicate a choice and also communicate that choice. Therefore, to grant a child adult rights is not problematic in and of itself; it merely requires careful consideration. However, the part of the guidelines that deals with sexually transmitted infections, contraceptive advice and abortion ought to be re-examined. A thirteen-year old, for example, may be competent to understand contraceptive advice but if she is considering an abortion or has a sexually transmitted infection, her problems are quite different. At the point at which she is seeking contraceptive advice, she is attempting to prevent future problems; if she is considering an abortion or has a sexually transmitted infection, she already has problems to contend with. Of course, this could be true even for medical problems that are not sexually related. The question, then, is whether and why standards of confidentiality ought to differ when the advice or treatment being sought is preventative rather than remedial?
In the case of a sexually transmitted infection, an abortion, or any type of other remedial medical problem, i.e., where a problem already exists and is being addressed rather than a one that is being prevented, confidentiality becomes complicated. The Guidelines state that although doctors ought to persuade their child patients to tell their parents about their medical problems or at least allow them, the doctors, to tell the parents, if the child patients do not want their problems disclosed, the doctors are obliged to maintain confidentiality. Although confidentiality per se is good because it respects the patient, whatever the age of the patient, in the case of a young teenager, it may not always be in the best interests of the patient. Consider a scenario where a thirteen-year old visits a doctor to consider an abortion. She does not want to discuss her pregnancy with her parents but visits her doctor knowing that under the new guidelines, confidentiality will be maintained. If the doctor advises her on whether or not to terminate her pregnancy, she may be pleased with the decision she makes on the basis of this advice. She may also be relieved that her visit and the problems discussed will be kept confidential. But the physical and emotional repercussions of experiencing an abortion will be less than easy for someone so young and her GP will not be able to provide the support she will need after she leaves the GP surgery. Should she decide not to terminate her pregnancy, she is bound to need support with regard to how to cope with a baby. In cases such as this, as well as in cases where the child is seriously ill and requires support that the GP will not be able to provide, confidentiality ought to be limited.
Maintaining confidentiality probably increases the numbers of young people who come forward for help when they need it. However, for precisely this reason, that they need help, doctors ought not to maintain confidentiality in circumstances where they are unable to help the patient as much as is required. Doctors may be good decision-makers. But to ask them to take on the role of parents for other people's children is a step too far.