Dilemma: Disputed consent in a minor

A MOTHER recently rang our GP surgery to make an appointment for her six-year-old to seek referral to child and adolescent services because of abnormal behaviour. Mum and child are both registered with the practice. The next day we received a message from the child’s father to say he objects to the referral and does not want it to go ahead. He is not registered and is unknown to the practice. What should we do?

A conflict where parents disagree about the management of their child’s healthcare arises quite frequently in practice. In the situation described here the child is also too young to be actively consulted about her views. Some disputes are related to administrative issues, such as the child’s registered address, and these along with clinical matters require a careful and consistent approach to try to resolve them.

It is useful to start with basic considerations. First, try to establish who has parental responsibility and therefore legal rights in relation to the child. These are helpfully summarised in the GMC’s 0-18 years: guidance for all doctors. This states that mothers and married fathers both have parental responsibility, as do unmarried fathers of children as long as they are named on the child’s birth certificate and the birth was registered after 15 April 2002 in Northern Ireland, 1 December 2003 in England and Wales and since 4 May 2006 in Scotland.

Unmarried fathers can acquire parental responsibility by way of a parental responsibility agreement with the child’s mother, or by getting a parental responsibility order from the courts. Married step-parents and registered civil partners can also acquire parental responsibility in the same ways.

Parents who divorce do not lose parental responsibility, and when a child is taken into care the parents will usually share responsibility with the local authority. Parents do lose parental responsibility if a child is adopted, and it can also be restricted by court order. Adoptive parents, individuals appointed as a child’s testamentary guardian, special guardians or those given a residence order will all have parental responsibility.

MDDUS advises healthcare professionals to get in touch if in any doubt about the legalities of parental responsibility.

In England, Wales and Northern Ireland these responsibilities continue up to the age of 18, and in Scotland up to the age of 16. If one parent has parental responsibility and the other does not, the consent of the parent with legal rights and responsibility is sufficient. However, it is often good practice to consider the other parent’s wishes too.

In many disputes both parents have parental responsibility and so have equal rights and responsibilities towards their child. Therefore the key consideration must always be what is in the child’s best interests.

Best interests are not always clear cut and due regard should be paid to cultural and religious beliefs, the views of those close to the child and other relevant professionals, e.g. school teachers and school nurses and the child’s own views (if they are mature enough). Any action must not be discriminatory and where there are options for treatment the decision should err on the side of being the least restrictive for future choices.

In making any decision about the child’s care therefore consider:

• What is the suspected condition?
• What are the options for investigation and treatment?
• Where will the care take place, e.g. GP or hospital?
• Does the patient or the parent have concerns or fears about the proposed plan?

Any fears expressed by the patient or parents should be addressed as far as possible. You must act in the child’s best interests having considered the options and their impact on your patient and keep careful notes of discussions with all parties in the child’s record.

Also, be open and honest about the care and the levels of communication that can be provided so that expectations are properly managed, e.g. how updates regarding the child’s health can be provided.

Looking at the scenario above: if Mum alone has parental responsibility she can consent to the referral and this can be made if it is clinically indicated and in the child’s best interests. Careful assessment and discussion with both parents is required and if both have parental responsibility the same principles apply. Consent from Mum alone would suffice if the action is in the child’s best interests, but if it were not, it is reasonable to refuse to make the referral.

Remember that in difficult cases we are happy to advise on the issues arising in these situations.