It is important for health professionals, particularly those with prescribing responsibilities, to understand the concept of Gillick competence when caring for young people and entering into a therapeutic relationship. In order to receive treatment, an individual must be able to consent; and in order to be able to consent, they must be deemed to have capacity.
Under current UK law, adults are usually presumed to be competent in order to consent to treatment. This is only questioned if their decision seems unwise or irrational to the health professional (Larcher and Hutchinson, 2010). With regards to children and young people, however, ability to consent is only possible if they are deemed to be ‘Gillick competent.’ This refers to the rights of a child who is under 16 years of age (Griffith, 2016).
The ‘right to consent’ to medical examination and treatment was decided by the House of Lords in Gillick v West Norfolk and Wisbech Health Authority in 1986 (Griffith, 2016). ‘Gillick’ refers to Mrs Victoria Gillick, who wrote to the Department of Health and Social Security (DHSS) in 1982, wanting confirmation and reassurance that her daughters – all under the age of 16 – would not be given advice regarding terminations or contraceptives without her specific consent.
Mrs Gillick asked this of the DHSS due to recent changes it had made to how such advice could be given to under-16s, which she objected to. The DHSS felt that advice or treatment was only appropriately handled by the prescribing doctor, alongside their expert clinical opinion. Subsequently, Mrs Gillick took the matter to court, but lost her case. This had huge repercussions for doctors – and now other health professionals. However, parental responsibility rights and consent issues warranted further discussion, which resulted in the development of further guidelines put forward by Lord Fraser, known as the Fraser guidelines (Cornock, 2018) (see Table 1).
» Along with maturity and intelligence will also be the professional's own ability to assess whether the child can understand aspects of choices to be made «
| The practitioner can continue if they are happy: | |
|---|---|
| 1 | That the girl under the age of 16 can understand the advice given |
| 2 | That the doctor cannot persuade the girl to tell her parents, or call the doctor themselves to discuss the issue with her parents |
| 3 | That the girl will continue in having sexual intercourse, with or without contraceptive treatment |
| 4 | That if the girl does not receive the advice or treatment, then her physical or mental health is likely to suffer |
| 5 | That it lies in the girl's best interests to receive contraceptive advice and treatment with-out the parents' consent |
Lord Fraser's principle concerns were focused on the welfare of girls under the age of 16 who would not stop having sexual intercourse, whether or not they had been given contraception advice (Griffith, 2021). He felt strongly that a doctor should give such advice – AND treatment – to girls under the age of 16, in accordance with the guidelines he had set.
Health professionals need to be confident in assessing Gillick competence in children under the age of 16 years; this stretches to other, medications and advice; for example, immunisations.
It is important to consider the child's maturity and level of intelligence, which does not necessarily arrive at the start of puberty (Griffith, 2013). Along with maturity and intelligence will also be the professional's own ability to assess whether the child can understand aspects of choices to be made, together with any potential consequences, and how willing and able the child is in order to make such informed choices.
It is also important to ensure that the child understands why the treatment is being proposed, including any risks or side effects, what alternatives may be available, and what might happen if they do not take the medication (Griffith, 2021). Such discussions and decisions to be made by the child should not be influenced by peers, family or friends, and the child should be able – if mature and intelligent enough – to make that decision freely (Larcher and Hutchinson, 2010).
Other influences might be emotional states, side effects of other medications, pain or misinformation. It may be necessary to involve the parents or other members of the multidisciplinary team in the decision-making process.
It has been over 40 years since ‘Gillick competence’ came into legal and ethical consent discussions, and it remains a valid component in healthcare practice today.
However, arguments continue regarding dependence on Gillick competence as a decision-making tool (Bart et al, 2024), so professionals need to think holistically about how to involve young people and those with parental responsibility in decisions about medical treatment.