Updated: May 7, 2020
By Usman Nasir
Before this article, check out the previous one called “Everything about ethics at interviews” to read about how to approach ethical scenarios and questions. Then you can come back to this article.
A 15-year old girl presents to your clinic requesting a contraceptive pill. She has come alone and does not want you to tell her parents. What do you do?
This scenario is centred around Gillick competence, Fraser Guidelines and consent in children. So, it is important to understand each of these three areas.
What is Gillick competence?
Children under 16 can consent to treatment, if they are deemed “Gillick competent” i.e. they fully understand what the treatment is, its risks and benefits and the availability of other options.
What are the Fraser Guidelines?
· More specific guidance to sexual health and contraceptive advice.
· Lord Fraser deemed contraceptive advice can be provided if:
o The child is mature enough.
o They cannot be persuaded to tell their parents
o They are most likely to continue sexual activity with or without contraception
o It is in their best interests.
Answering the question
· Firstly, it needs to be determined if the 15-year old girl is Gillick competent. Can she understand the information being told to her, process it, weigh up her options and then communicate her thoughts back? Does she fully understand the nature of the treatment?
· Then you would explore her ideas, concerns and expectations (use the ICE acronym to remember this). Why does she want contraception? Is there anything she is concerned about? Is she being taken advantage of? Is she still sexually active? Why does she not want to inform her parents?
· You could then encourage her to tell her parents that she is sexually active.
· But if she is Gillick competent, then doctor-patient confidentiality should be maintained unless she is at risk of harm.
· However, if you as the doctor feel that the girl’s mental or physical wellbeing is being put at risk (i.e. abuse or being taken advantage of) by having sexual activity, then confidentiality can be broken in their best interests.
· Important consideration: If the girl were under 13, then this would need to be reported immediately through child protection protocols.
Using the ethical pillars
· The girl’s AUTONOMY should be respected here, if she is deemed Gillick competent.
· CONFIDENTIALITY is still an underlying theme.
· BENEFICENCE is also an integral consideration, as the focus is the best interests of the girl.
Scrubbed up Tips
· Do not forget referring to the ethical pillars.
· Remember this could also be a role play station, so it might be a good idea to set up a mock station with friends or family as practice.
· Make sure you have a solid understanding of Gillick competence, Fraser Guidelines and consent in children (NICE and the BMA ethics toolkit for medical students have great resources for this).
Gillick competence and Fraser Guidelines definition –
https://learning.nspcc.org.uk/media/1541/gillick-competency-factsheet.pdf NSPCC Gillick competency and Fraser guidelines.