Practice dilemma: Patient's parent upset over contraceptive script
MDU medicolegal adviser Dr Beverley Ward explains the legal position on consent and confidentiality, concerning an under-16's script for the Pill.
A 14-year-old female patient wants to discuss different contraception options. She has been in a relationship with her boyfriend for two years and, although not yet sexually active, would like to start taking some form of contraception in case she becomes sexually active in the near future. You discuss the emotional and physical implications of a sexual relationship, as well as options for contraception, before prescribing her one month's supply of a combined oral contraceptive pill, requesting that she returns in a fortnight to report how she was finding the medication. You also encourage her to discuss her decision with her parents. Days later your practice manager receives a letter of complaint from the girl's mother. The patient disclosed she had been prescribed the Pill, and her mother was unhappy that this decision had been reached without her consent. How should you respond?
As young patients grow up and start to visit their GP alone, it can be difficult for the doctor to balance the ethical issues of parental rights and patient confidentiality. What is vital is that the GP does not forget their overriding duty to make a decision that ensures the welfare and best interests of the young person.
When a patient under the age of 16 visits their GP, the doctor must assess whether the patient has sufficient capacity to provide valid consent to treatment. This capacity is often referred to as Gillick competence, reflecting the House of Lords judgment in Gillick vs West Norfolk and Wisbech Area Health Authority.1
In its guidance on children and young people, the GMC rules:2 ‘You must decide whether a young person is able to understand the nature, purpose and possible consequences of investigations or treatments you propose, as well as the consequences of not having treatment.
‘Only if they are able to understand, retain, use and weigh this information, and communicate their decision to others, can they consent to that investigation or treatment. That means you must make sure all relevant information has been provided and thoroughly discussed before deciding whether or not a child or young person has the capacity to consent.'
When considering whether to prescribe contraception to a patient under the age of 16, it is important to remain vigilant to anything which may suggest they are involved in an abusive relationship. If you fear that they may be or that there is a risk to their health, safety or welfare, you may decide that this outweighs their right to confidentiality and wish to refer to locally agreed child protection procedures to ensure their safety.
If a patient is under the age of 13, they are considered by law unable to consent.1 If you are approached by a patient of this age who requests contraception, you should discuss the implications of this request with the designated doctor or person at the PCT.
From the situation outlined in the case study, it sounds like after discussions with the patient, you decided that she was capable of consenting to her own medical care. It is likely that the patient is competent to make decisions relating to the disclosure of confidential information to her mother and, as such, she is owed the same duty of confidentiality as any other patient.
You should disclose information about her treatment to her mother only if you have the patient's consent. You may wish to speak to the patient directly and try to gain her permission to discuss the situation. If the patient consents, you may respond to the mother's complaint explaining why you decided not to involve her in her daughter's medical treatment this time.
If the patient does not give you consent to discuss her treatment, then you must respect this decision and not disclose any information to her mother. You may wish to respond to the patient's mother stating that you are unable to discuss another patient's treatment without their consent.
Freely given consent
If the patient does consent to the disclosure of her medical information, it is important that you make sure her permission is given freely – this can be difficult to assess at times in some families. You may wish to try and speak to the patient alone so that you can gauge whether she is truly happy with the disclosure or if she is only complying under duress.
Dr Beverley Ward is a retired GP and a medicolegal adviser at the Medical Defence Union
1 GMC. Zero to 18 years: guidance for all doctors. 2007
2 UKHL 7. Gillick vs West Norfolk and Wisbech Area Health Authority. 1985