Some implications of the Human Rights Act 1998 for the medical treatment of children

Although the Gillick decision was hailed as an important step in the furtherance of respect for children's autonomy, subsequent judgments seemed to undermine this important principle. While it would be difficult to criticise the outcomes of some of the key cases, the reasoning by which these were achieved is rather more contentious. There have been some interesting discussions suggesting more constructive approaches but there is still a great deal of anecdotal evidence indicating that conservative assessments of children's ability to be involved in decisions about their medical treatment remain the norm. The new Department of Health consent forms should help to create a climate where assessment of a child's competence will become more sophisticated. This paper will argue that the Human Rights Act 1998 offers another opportunity to reassess more traditional approaches to children's capacity; indeed, this could be violation, inter alia, of the right not to be subject to inhuman and degrading treatment under Article 3 in extreme circumstances and the right to private and family life enshrined in Article 8. Clearly, it is not always practicable to carry out assessments rigorously and some health professionals may feel they do not have the expertise to do this, but some basic criteria could assist here; courts are not likely to expect more than a demonstration that best endeavors have been employed in reasoned decision-making. Additionally, other privacy rights may have implications for the medical decision-making process as it affects children and their carers particularly where conflict arises. Disputes may also ensue from the right to manifest religion and other beliefs",' under the Act. This paper will explore how such challenges to those responsible for the medical treatment of children may fare.     

Sterilisation of the intellectually disabled: the need for legislative reform

This article examines the recent decision of the Full Court of the Family Court in Re Marion dealing with the question of sterilisation of intellectually disabled minors and in particular, the question of whether a parent or guardian can lawfully consent to a sterilisation operation upon an intellectually disabled minor or whether court approval is required before such an operation can lawfully be performed. The article goes on to critically examine legislation in force in various Australian jurisdictions concerning involuntary sterilisations and substituted consent as well as legislative reforms that have been proposed in this area.     

Queensland general practitioners' applications of the "mature minor" principle: the role of patient age and gender

Most Australian jurisdictions do not have legislation that stipulates an age by which a minor can make their own medical treatment decisions. Instead, they rely on Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112, an English common law decision that recommends individual assessments of "maturity". This study explores how medical practitioners in the State of Queensland understand and apply this legal authority when faced with a young person wishing to make a contentious medical treatment decision. Almost 200 doctors made decisions about a hypothetical patient's competence and confidentiality, and detailed their reasoning in an open-ended format. The data indicate that the vagaries of existing legal criteria allow for a range of philosophical perspectives and idiosyncratic heuristics to play a role in assessment practices, and that particular combinations of patient age and gender made these cognitive shortcuts more likely to occur. A notable proportion of such processes are not consistent with legal guidelines, and this has implications for general practitioners' vulnerability to litigation as well as young patients' treatment trajectories.     

Competence to give informed consent for medical procedures

This study shows that referrals to psychiatry for evaluation for competence to give informed consent generally were made on patients who refused medical treatment. In this sample of referred patients, the only patients found to be incompetent to give informed consent were those with organic brain syndromes. No one with either schizophrenia or depression was found to be incompetent. It is possible that schizophrenic and depressed patients may generally be competent to give informed consent to medical treatment. This finding might be true notwithstanding the fact that many such patients have been found in other studies to be incompetent to consent to voluntary psychiatric treatment. For example, a patient may have delusions that others can read his mind and thoughts, but he still can understand that he needs dialysis for renal failure. Alternatively, it may be relatively rare that an emergency procedure is necessary before a patient's psychosis can be brought under control and consequently internists and surgeons themselves may prefer to wait. The significance of the results is unclear. Because of active interest in the doctrine of informed consent for psychiatric and medical patients by both physicians and attorneys and the few studies within this population, there is a strong need for more study regarding competence to give informed consent. Further study is especially important for psychotic patients for whom psychiatric consultation is not requested.(ABSTRACT TRUNCATED AT 250 WORDS)     

Consent to Treatment for Transgender Youth: The Next Chapter – Bell & Anor v The Tavistock and Portman NHS Foundation Trust & Ors

In September 2021, the Court of Appeal reversed the controversial decision of Quincy Bell v Tavistock and Portman NHS Trust in a victory for transgender rights. At first instance, the Divisional Court had set a high legal threshold for transgender children to attain Gillick competence to consent to treatment with puberty blockers – effectively restricting access to treatment for many. On appeal, the Court of Appeal held that children are capable in law of giving valid consent to treatment for gender dysphoria, and court authorisation would not be routinely required before children could access such treatment. This note considers the implications of the Court of Appeal decision for the law on minors and consent to medical treatment in the transgender health context.     

Minors' rights to consent to treatment: navigating the complexity of State laws

State laws recognize that a competent adult patient has the right to consent to or refuse medical treatment. While the law is clear with regard to the right of competent adults, state statutes are more complicated when the patient is a minor. While the law should, and does, attempt to balance the rights and obligations of parents and guardians against the access and privacy rights of minors, complicated state statutory schemes often fail to simultaneously address those contrasting goals in a consistent and uniform manner. The result is a confusing set of seemingly arbitrary and sometimes conflicting provisions that require the detailed attention of healthcare providers to ensure legal compliance. With the aim of helping healthcare practitioners meet their legal obligations, this Article examines state laws governing minor's consent rights byfocusing on the instances in which a minor's parent, guardian, or other authorized adult is permitted to consent to treatment on behalf of a minor and the instances in which a minor is authorized to act independent of adult intervention.     

Restoring Responsibility: Promoting Justice, Therapy and Reform Through Direct Brain Interventions

Direct brain intervention based mental capacity restoration techniques—for instance, psycho-active drugs—are sometimes used in criminal cases to promote the aims of justice. For instance, they might be used to restore a person’s competence to stand trial in order to assess the degree of their responsibility for what they did, or to restore their competence for punishment so that we can hold them responsible for it. Some also suggest that such interventions might be used for therapy or reform in criminal legal contexts—i.e. to make non-responsible and irresponsible people more responsible. However, I argue that such interventions may at least sometimes fail to promote these responsibility-related legal aims. This is because responsibility hinges on other factors than just what mental capacities a person has—in particular, it also hinges on such things as authenticity, personal identity, and mental capacity ownership—and some ways of restoring mental capacity may adversely affect these other factors. Put one way, my claim is that what might suffice for the restoration of competence need not necessarily suffice for the restoration of responsibility, or, put another way, that although responsibility indeed tracks mental capacity it may not always track restored mental capacities.     

Developmental trends in adolescents' psychological and legal competence to consent to abortion

United States Supreme Court has affirmed the right of states to require parental consent or notice from minors seeking abortion. We examine an underlying presumption that minors are not competent to consent to abortion. Participants (N=75 age 13–21, seeking a pregnancy test at a women's medical clinic) completed an interview that was audiotaped and scored on four cognitive and volitional criteria of legal competence. Competence was compared in three age groups (≤15; 16–17; 18–21) for participants who considered abortion and for those who did not. Adolescents age 16–17 and adolescents ≤15, who considered abortion, appeared as competent as legal adults; only≤15-year-old adolescents who did not consider abortion appeared less competent. Regression analysis was used to identify psychosocial predictors of competence. Results challenge the presumption that minors are not competent. An alternate policy based upon informed consent and empowerment of minors as decision makers is proposed.     

Competence to consent to treatment as a psycholegal construct

The issue of whether civilly committed patients should be extended the right to accept or refuse treatment has generated much controversy and litigation during the past 15 years. In general, the current rule is that in nonemergency situations, individuals who are competent to give informed consent to treatment should be extended the right to refuse it. Obviously, the manner in which this rule is implemented partly depends on how competence to consent to treatment is defined and measured. Most researchers have implicitly assumed that an understanding of treatment information is the sole criterion of competence. It is argued that such a definition may be incomplete and is in need of reexamination. Following a review and analysis of the relevant legal and psychological literature, a comprehensive construct of competency to consent to treatment is proposed and future directions for research are discussed.     

The MacArthur Treatment Competence Study. III

Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, as well as three groups of non-ill persons in the community who were matched with the hospitalized patients on age, gender, race, and socioeconomic status. Significant impairments in decisional abilities were found for only a minority of persons in all groups. Both the schizophrenia and depression groups manifested poorer understanding of treatment disclosures, poorer reasoning in decision making regarding treatment, and a greater likelihood of failing to appreciate their illness or the potential benefits of treatment. Deficits were more pronounced, however, among patients with schizophrenia. Implications are discussed for policy designed to protect the rights and welfare of patients with mental illness who are at risk of incompetent refusal or consent when making treatment decisions.     

Donation of 'spare' fresh or frozen embryos to research: who decides that an embryo is 'spare' and how can we enhance the quality and protect the validity of consent?

This paper analyses elements of the legal process of consent to the donation of 'spare' embryos to research, including stem-cell research, and makes a recommendation intended to enhance the quality of that process, including on occasion by guarding against the invalidity of such consent. This is important in its own right and also so as to maximise the reproductive treatment options of couples engaged in in vitro fertilisation (IVF) treatment and to avoid possible harms to them. In Part 1, with reference to qualitative data from three UK IVF clinics, we explore the often delicate and contingent nature of what comes to be, for legal purposes, a 'spare' embryo. The way in which an embryo becomes 'spare', with its implications for the process of consent to donation to research, is not addressed in the relevant reports relating to or codes of practice governing the donation of embryos to research, which assume an unproblematic notion of the 'spare' embryo. Significantly, our analysis demonstrates that there is an important and previously unrecognised first stage in the donation of a 'spare' embryo to research, namely: consent to an embryo being 'spare' and so, at the same time, to its disuse in treatment. This is not explicitly covered by the Human Fertilisation and Embryology (HFE) Act 1990, as amended by the HFE Act 2008. Having identified this important initial stage in the process of consent to the donation of a 'spare' embryo to research in conclusion to Part 1, in Part 2 we analyse the idea of consent to an embryo's disuse in treatment on the basis that it is 'spare' with reference to the legal elements of consent, namely information as to nature and purpose, capacity, and voluntariness. We argue that there are in fact three related consent processes in play, of which the principal one concerns consent to an embryo's disuse in treatment. If the quality of this first consent is compromised, in turn this will impact on the quality of the consent to the donation of that 'spare' embryo to research, followed by the quality of consent to future cycles of assisted reproduction treatment in the event that these are needed as a result of a donation decision. The analysis overall is of central relevance to the debate as to whether, and if so when, it should be permissible to request the donation of fresh embryos for research, as opposed to those that have been frozen and, for instance, have reached the end of their statutory storage term. This has a particular bearing on the donation of embryos to stem-cell research since there is a debate as to whether fresh embryos are most useful for this.     

An Investigation of the Construct of Competence: A Comparison of the FIT,the MacCAT-CA,and the MacCAT-T

The 1990s witnessed Supreme Court decisions in both Canada and the United States on issues of competence that went against longstanding case law, psychological research, and common sense. These decisions held that there is to be one standard for all types of criminal competencies. The present research attempts to investigate whether this is an appropriate assumption and thus tests whether there are one or more constructs that underlie different types of competence. Two divergent types of competence were examined, competence to stand trial (both Canadian and American conceptualizations) and competence to consent to treatment, to determine if these different types of competence share a common underlying construct. Confirmatory factor analysis was used to test this question and results indicate that there is a common construct that underlies different types of competence.     

Conundrums with penumbras: the right to privacy encompasses non-gamete providers who create preembryos with the intent to become parents

To date, five state high courts have resolved disputes over frozen preembryos. These disputes arose during divorce proceedings between couples who had previously used assisted reproduction and cryopreserved excess preembryos. In each case, one spouse wished to have the preembryos destroyed, while the other wanted to be able to use or donate them in the future. The parties in these cases invoked the constitutional right to privacy to argue for dispositional control over the preembryos; two of the five cases were resolved by relying on this right. The constitutional right to privacy protects intimate decisions involving procreation, marriage, and family life. However, when couples use donated sperm or ova to create preembryos, a unique circumstance arises: one spouse--the gamete provider--is genetically related to the preembryos and the other is not. If courts resolve frozen preembryo disputes that involve non-gamete providers based on the constitutional right to privacy, they should find that the constitutional right to privacy encompasses the interests of both gamete and non-gamete providers. Individuals who create preembryos with the intent to become a parent have made an intimate decision involving procreation, marriage, and family life that falls squarely within the the right to privacy. In such cases, the couple together made the decision to create a family through the use of assisted reproduction, and the preembryos would not exist but for that joint decision. Therefore, gamete and non-gamete providers should be afforded equal constitutional protection in disputes over frozen preembryos.     

A Clinical Study of Competency to Consent to Hospitalization and Treatment in Geriatric Inpatients*

Abstract: This study used a Competency Questionnaire modified for medical surgical patients (CQ‐Med). Twenty‐nine patients (ages 65–94 years) admitted to a geriatric medicine unit were studied. Along with the CQ‐Med, patients were administered several WAIS‐R subtests, the Blessed Dementia Scale (BDS), and Mini Mental State Exam (MMSE). Additionally, a blind forensic evaluation for competency to consent to hospitalization and treatment was performed for the purpose of validation of the CQ‐Med. Results of the study found that, as expected, increased age was correlated with decreasing performance on the CQ‐Med and decreased findings of competence by clinical exam. However, there was great variability within each age group, demonstrating individual differences in the progress of declining competency. CQ‐Med scores also correlated well with the WAIS‐R subtest raw and scaled scores. Scores on the MMSE and BDS were less well correlated. The CQ‐Med may be a useful adjunct in assessing declining competency in geriatric patients.     

Coercion,competence, and consent in offenders with personality disorder

Competence to consent to treatment has not previously been examined in a personality disorder cohort without comorbid mental disorder. We examined competence and coercion in 174 individuals diagnosed with severe personality disorder using two validated tools (the MacArthur Competence Assessment Tool for Treatment and the MacArthur Coercion Assessment Scale – Short Form). Competence was not categorically impaired, but there were variations within the sample on dimensional competence measures. Further, there were significant negative correlations between experienced coercion and competence. Higher coercion scores were associated with two components of competence: lower understanding and reasoning. Patients who consented to treatment had higher scores on competence measures and experienced less coercion. These findings suggest that therapeutic approaches that decrease experienced coercion and increase competence may increase the engagement of individuals diagnosed with severe personality disorders in treatment.     

Autonomy and the competent patient's right to refuse life-prolonging medical treatment--again

This article discusses the recent decision of the Court of Appeal of the United Kingdom in Re B (Adult: Refusal of Medical Treatment) [2002] 2 All ER 449, which confirmed the common law right of a competent patient to refuse medical treatment, even though exercise of the right would (and later did) result in the patient's own death. Re B indicates that if a competent refusal is not respected, health professionals and hospitals face the prospect of awards of damages being made against them for unlawful trespass.     

The capacities of minors to exercise voluntariness in medical treatment decisions

The legal standard for informed consent to medical treatment requires that the consenter be informed, competent, and acting voluntarily. The voluntary requirement of a valid consent was investigated by comparing forty 9- and 10-year-old children and forty 14- and 15-year-old adolescents (both generally presumed to be incapable of voluntary consent) with 47 young adults ranging in age from 21 to 25 (legally presumed to be deciding voluntarily) on responses to three hypothetical medical decision vignettes. The degree of parental influence was varied within each vignette to study the salience of parental influence in medical decision making. In two of three medical decision vignettes, most participants were deferent to parental wishes and few differences were found between children, adolescents, and young adults in their responses to parental influence. Differences between age groups were found in response to a kidney donation vignette. Children were significantly more likely to defer to parents than either adolescents or young adults. Adolescents were more likely to defer to parents than young adults, although this finding only approximated statistical significance. Implications of these findings for legal authorities, social policy makers, and families are discussed.     

Autonomy, guardianship and mental disorder: one problem, two solutions

The law in England and Wales governing both the provision of medical care in the case of adults with incapacity and the provision of care and treatment for mental disorder presents serious problems for the principle of patient autonomy. The adult with incapacity has no competence either to consent to or refuse medical treatment but the law provides no statutory structure for substitute decision making on that adult's behalf. On the other hand the law does allow a person with mental disorder to be treated for that disorder despite his or her competent refusal. The nature of these inconsistencies is considered and the implications which flow from the singling out of mental disorder are examined with reference to experience in two Australian jurisdictions. The current proposals for reform of the Mental Health Act are then considered in the light of the conclusions drawn.     

Reconciling Autonomy and Beneficence in Treatment Decision-Making for Companion Animal Patients

This article explores how the concept of consent to medical treatment applies in the veterinary context, and aims to evaluate normative justifications for owner consent to treatment of animal patients. We trace the evolution of the test for valid consent in human health decision-making, against a backdrop of increased recognition of the importance of patient rights and a gradual judicial espousal of a doctrine of informed consent grounded in a particular understanding of autonomy. We argue that, notwithstanding the adoption of a similar discourse of informed consent in professional veterinary codes, notions of autonomy and informed consent are not easily transferrable to the veterinary medicine context, given inter alia the tripartite relationship between veterinary professional, owner and animal patient. We suggest that a more appropriate, albeit inexact, analogy may be drawn with paediatric practice which is premised on a similarly tripartite relationship and where decisions must be reached in the best interests of the child. However, acknowledging the legal status of animals as property and how consent to veterinary treatment is predicated on the animal owner’s willingness and ability to pay, we propose that the appropriate response is for veterinary professionals generally to accept the client’s choice, provided this is informed. Yet such client autonomy must be limited where animal welfare concerns exist, so that beneficence continues to play an important role in the veterinary context. We suggest that this ‘middle road’ should be reflected in professional veterinary guidance.     

Can a Woman Rape a Man and Why Does It Matter?

Under current UK legislation, only a man can commit rape. This paper argues that this is an unjustified double standard that reinforces problematic gendered stereotypes about male and female sexuality. I first reject three potential justifications for making penile penetration a condition of rape: (1) it is physically impossible for a woman to rape a man; (2) it is a more serious offence to forcibly penetrate someone than to force them to penetrate you; (3) rape is a gendered crime. I argue that, as these justifications fail, a woman having sex with a man without his consent ought to be considered rape. I then explain some further reasons that this matters. I argue that, not only is it unjust, it is also both a cause and a consequence of harmful stereotypes and prejudices about male and female sexuality: (1) men are ‘always up for sex’; (2) women’s sexual purity is more important than men’s; (3) sex is something men do to women. Therefore, I suggest that, if rape law were made gender neutral, these stereotypes would be undermined and this might make some (albeit small) difference to the problematic ways that sexual relations are sometimes viewed between men and women more generally.