The retreat from Gillick

Gillick competence: an inadequate guide to the ethics of involving adolescents in decision-making

Developmentally, adolescence sits in transition between childhood and adulthood. Involving adolescents in their medical decision-making prompts important and complex ethical questions. Originating in the UK, the concept of Gillick competence is a dominant framework for navigating adolescent medical decision-making from legal, ethical and clinical perspectives and is commonly treated as comprehensive. In this paper, we argue that its utility is far more limited, and hence over-reliance on Gillick risks undermining rather than promoting ethically appropriate adolescent involvement. We demonstrate that Gillick only provides guidance in the limited range of cases where legal decisional authority needs to be clarified. The range of cases where use of Gillick actually promotes adolescent involvement is narrower still, because several features must be present for Gillick to be enacted. Each of these features can, and do, act as barriers to adolescent involvement. Within these limited situations, we argue that Gillick is not specific or strong enough and is reliant on ethically contestable principles. Moreover, in most situations in adolescent healthcare, Gillick is silent on the ethical questions around involving adolescents. This is because it focuses on decisional authority-having the final say in decision-making-which is one small subset of the many ways adolescents could be involved in decision-making. The implication of our analysis is that use of Gillick competence tends to limit or undermine adolescent involvement opportunities. We propose that those working with adolescents should be judicious in seeking Gillick's guidance, instead drawing on and developing alternative frameworks that provide a comprehensive model for adolescent involvement.

Decision-making about children's mental health care: ethical challenges

Children and young people are usually referred to specialist child and adolescent mental health services (CAMHS) by adults because of concerns raised by other adults. Most CAMHS consider them from a developmental perspective and as individuals in the context of their families and other relationships/systems. In this article I discuss ethical and legal challenges posed by making decisions with and about children and young people within CAMHS, with particular reference to duty of care; the rights of minors' and parents'; capacity and consent; and disagreement between decision-makers. It is important to involve children and young people in decision-making, and I suggest ways of acheiving this.

Ashley, Two Born as One, and the Best Interests of a Child

What is in the best interests of a child, and could that ever include interventions that we might regard as prima facie detrimental to a child's physical well-being? This question is raised a fortiori by growth attenuation treatments in children with severe neurological disorders causing extreme developmental delay. I argue that two principles that provide guidance in generating a conception of best interests for each individual child yield the right results in such cases. The principles are as follows: the potentiality principle, whereby every child should be able to develop its potential and is entitled to receive certain help in doing so, and the principle of psychosomatic harmony, whereby every human being is entitled to treatment that is appropriate to or enables a life in which mind and body are in tune with each other. These principles indicate a certain response to what we can call Ashley-type cases and admit certain caveats.

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child's refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children's consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.