Practice dilemma - A 14-year-old requests termination of pregnancy

Competency and consent are issues raised by a girl's abortion request.

The dilemma

A 14-year-old girl bursts into tears during an emergency appointment and tells you that she is pregnant after having consensual sex with a 15-year-old boy at her school. The girl is adamant she wants you to arrange for an abortion. The family has been with the practice for many years and you suggest that she makes an appointment to discuss the matter with her regular GP in the practice, but she says she cannot face him. How should you proceed and how old is old enough when it comes to making personal choices regarding sexual health?

A GP's view

Dr Louise Newson is a GP in the Midlands

Although you may not feel comfortable dealing with this situation, it needs to be addressed properly in this consultation.

It can be difficult for patients to book appointments with their registered GP and she may have to wait several weeks for an appointment with her regular GP, which is not acceptable in this case.

This patient is under 16 and if you assess her as competent to consent to treatment using the Fraser guidelines, she can legally proceed to a termination of pregnancy (TOP) without her parents being informed.

The Fraser guidelines, while focusing on contraception, also extend to the question of TOP. If she is Fraser competent, she does not need parental consent to have treatment.

It is very important that you reiterate to her the rules of confidentiality and that your consultation and the details about it are confidential.

However, you should encourage her to talk to her parents or an adult about her situation. Many teenagers who undergo a TOP in the UK do inform their parents.

Local arrangements regarding TOP often vary across regions. It is important that you are familiar with your local arrangements. You should give her information about medical and/or surgical TOP, depending on her gestation and which procedure she is most likely to have.

This consultation should also be an opportunity to discuss contraception and give her written information about her choices for contraception in the future.

It is important not to be judgmental about her situation and gain her trust during the consultation.

You should offer her a follow-up appointment to arrange formal contraception for her.

Seek medico-legal advice from your medical indemnity organisation about your statutory and ethical duties, and the rights of patients and/or their parents, if you have any uncertainty. You may wish to discuss the case with her registered GP.

A medico-legal opinion

Dr Gail Gilmartin is a senior medical adviser at MDDUS

Child consent can be complicated, especially when the patient is at an age where their maturity to make decisions about medical interventions could be in question.

Young people are presumed to be competent to make decisions regarding their own medical care at 16. Below that age, it is up to the GP's judgment to decide if the child demonstrates sufficient understanding and maturity.

In this situation, the 14-year-old girl should be encouraged to involve her parents or another supportive adult, for example, an older sibling, in the decision-making process. The GP should check the girl's general health and advise her of the medical aspects of her request for a TOP.

Despite the girl not wanting to face her regular GP, she should be made aware that relevant information about the consultation will be on her medical record and although these records are confidential, other practitioners might see them.

During the consultation, the doctor should form a clear view about the patient's capacity. If the girl is deemed competent and chooses referral for TOP, having been fully advised of the likely procedures, a referral should be made.

In view of the patient's age, it would be helpful to speak to a local family planning doctor to be aware of their own procedures and protocols.

The GMC's 0-18 years: guidance for all doctors offers specific advice on matters of consent in children and should be followed.

A patient's view

Danny Daniels is an expert patient

Ideally, it would help the GP in reaching a solution to this dilemma if a parent or guardian could be informed, but if the patient refuses to do so, there is very little that the doctor can do.

Patient confidentiality comes immediately to the forefront and the GMC advice is quite specific in stating that 'you cannot persuade the young person to tell their parents or to allow you to tell them. Any refusal should be respected.'

There are no definitive solutions concerning underage pregnancies.

Given the emotions and fears that are obviously being experienced by the patient, the dilemma is now being shared with the GP.

The matter of competency on the part of the child to make an informed choice in this situation is one of the avenues the GP should pursue.

Lord Scarman, following the Gillick ruling, stated in the House of Lords that 'it is not enough that she should understand the nature of the advice which is being given: she must also have a sufficient maturity to understand what is involved'.

He added: 'Parental right yields to the child's right to make his own decisions when he reaches a sufficient understanding and intelligence to be capable of making up his own mind on the matter requiring decision.'

Regarding the difficult question of how old is old enough, the Family Planning Association states: 'Abortion is legal in the UK regardless of your age.'

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