Ethics and law

Autonomy

This is the recognition that a competent adult, with full capacity of understanding, is able to make decisions about their own lives and bodies—even where this may seem counter to their well-being and survival. Failure to respect this fundamental right may lead to the clinician being accused of assault.

Nonmaleficence

There is an understanding that any decision or treatment offered to a patient must not be harmful. The original Hippocratic Oath stated “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing”. Medical intervention, however beneficial to the patient, must balance the possible risk of harm to the patient. Where that risk is significant then intervention needs careful consideration and may even be inappropriate.

Beneficence

The aim and intention of the clinician is to act in the best interests of the patient and ensure that any advice or treatment provided is for the benefit of the patient.

Justice

This principle requires the clinician to be fair and honest in all dealings with their patient.

These four, often quoted, core principles, however, do present difficulties when applied to children and young people at all the stages of their emotional and intellectual development. In the intellectually competent young person, the principle of autonomy has a greater importance and the young person can agree to interventions without the permission of their parents or guardian. When, however, the competent young person refuses an intervention that is thought by others to be in their best interests, then ‘beneficence’ seems to take precedence and the opinion of the young person can be discounted.

When the child is considered to be ‘intellectually immature’, decisions will, understandably, be made by their parents or guardians. The principle of autonomy and nonmaleficence then becomes difficult to apply, but there would still be a place for understanding a child’s requests and concerns and an aim to respect these where possible. A young child will certainly object to a simple blood test but it would be argued that they are unable to understand the need for the test and the consequences of their objection. The young child is not allowed to make ‘unwise’ decisions and so it is the parents and clinicians who will agree that the intervention is in the child’s best interest—beneficence.

It can be argued that the principle of autonomy does not apply to children and young people. UK law supports this view as ‘…the child’s welfare shall be the court’s paramount consideration’ and so allows the court to make decisions on behalf of the child.

In practice, those attributes necessary to make informed decisions and act autonomously—to be able to understand the terms used in any information given, to process and rationalise that information and to understand the potential consequences of any decision—evolve over many years. The ability to act in an autonomous way will vary between individuals, between the issues under discussion and the range of potential outcomes for that decision, and this ability will mature over time. This was recognised by the UK courts:

“As a matter of Law, the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” —Lord Scarman (1985)

Confidentiality

The common law in the UK requires doctors to keep all personal information provided by patients as confidential and that an understanding of such an arrangement is essential to the maintenance of trust between the two parties. The General Medical Council, similarly, requires doctors to recognise that confidentiality is central to their interaction with patients. Ensuring patient confidentiality is, therefore, an ethical, professional and a legal requirement.

The principle, however, is not absolute and the doctor may share confidential information in certain circumstances. This would include situations where the patient agrees to the sharing of the information as in an individual with a medical problem asking for some details to be shared with a new employer, or when there is a court order to share the information such as a mental health assessment to place before a court which can then influence any sentence given. A more extreme example would be a need to share information that has a wider public interest such as when a patient makes a credible threat of violence to others.

Confidentiality requires further consideration in paediatric practice. Children and young people are entitled to the same standards of confidentiality as other patients, but their rights are not absolute and can be overridden when there is a clear justification, such as the risk of significant harm. There are situations where a mature, competent teenager would expect their medical information to remain confidential, including keeping that information from their parents. In such a situation, this would include denying parents the right to automatically view the medical records of the young person. If the medical practitioner felt that there was an exceptional reason that justified disclosure without consent, then the young person should be told of the need to break their confidentiality and the reasons fully explained. In the absence of any such reason justifying disclosure, they should be encouraged, but not forced, to share their health information with their parents.

The sharing of information about a child with the parents would, in most situations, be expected practice, but where there is a concern about the welfare of the child then some aspects of the care may be withheld—for example, if a carer is suspected of poisoning a young child—until more information is obtained.

Where there are safeguarding concerns then the paediatrician must share information with other members of the multidisciplinary team involved in child protection—social services and police. It would, however, be considered good practice to advise the parents that this was the intended action.

The four core principles have, however, been expanded and developed by various declarations over many years. Some, such as Declaration of Geneva, Declaration of Human Rights and the UN Rights of the Child, have all contributed to the establishment of codes of practice for the clinician.

The General Medical Council of the UK sets expected standards of medical care and training and has produced a series of booklets which outline important issues for the clinician.

The GMC also produces specific standards of best practice for all doctors who have any contact with children and young people under the age of 18 years.