Guide to ethics of treating children published

News roundup

A guide to help doctors treating children to avoid pitfalls such as those highlighted by inquiries into children's heart surgery at Bristol, organ retention at Alder Hey hospital in Liverpool, and research on babies at North Staffordshire hospital was published by the BMA's ethics committee this week.

The 267-page guide comes from a steering group chaired by the child law expert Allan Levy, QC. Other members included child psychiatrist Sir Michael Rutter; Michael Wilks, chairman of the BMA's medical ethics committee; and Dr Vivienne Nathanson, BMA's head of health policy research.

The book maps a route through what can be a legal and ethical minefield for doctors. Mr Levy said its aim was to ease the path of doctors and other professionals who are often involved in controversial decisions about whether, and to what extent, children should receive particular medical treatment.

Competent adults have an absolute right to refuse treatment, but issues of consent are much more complex where children are concerned. Parents can consent to treatment on behalf of their children but not if the treatment is against the child's best interests.

Older children, if they can understand the treatment proposed, can consent on behalf of themselves. But what if the parent disagrees? Then the position is legally complex, and the law of Scotland differs from that in England, Wales, and Northern Ireland. For patients aged under 18, the courts may also take treatment decisions.

The law is constantly developing through court cases---making it clear recently, for example, that consent by one parent alone is insufficient for non-therapeutic procedures, such as  male infant circumcision. And the  Human Rights Act, which came into force in October, is expected to produce a whole new line of cases.

Research is a particularly fraught area. Parents can consent to treatment that is in the child's best interests, but research generally benefits not the individual child but children in general.

The  GMC advised in 1991 that, strictly speaking, parents could not give consent to procedures that were of no benefit to the particular child and might carry some risk of harm. The BMA's new guide says: It is now widely accepted that from an ethical perspective research can be carried out on children, when there is no expected benefit for them individually, provided there is minimal risk, strict safeguards and no objection from either the child or parents.

Reinforcing the message from the Bristol heart surgery debacle, the guide says that doctors carrying out innovative treatment must monitor closely whether the outcomes from new procedures and from their mastery of them fall below the success rate gained by other practitioners.

Consent, Rights and Choices in Health Care for Children and Young People is available from the  BMJ bookshop.

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