When I was four-and-a-half, something scary happened. I was woken early, had a mask clamped to my face and was wheeled into a white room. I thought I was being abducted. But it was an operating theatre and I was having my squint corrected. I guess they forgot to tell me.
That wouldn’t happen today, but how good are doctors and parents at involving children in medical decisions? A review, published in the International Journal of Nursing Studies in 2008, found that doctors rarely asked children for their opinions. A 2014 study from the University of Surrey found that children between the ages of seven and 16 with cancer were not involved in treatment decisions because “refusal was not an option”. New recommendations last month from the American Academy of Pediatrics (AAP) remind doctors that children should know the options for diagnosis and treatment. They state that children as young as seven can understand and agree to tests or treatment.
Dr Joe Brierley, a consultant in paediatric and neonatal intensive care at Great Ormond Street children’s hospital and a vice-chair of its clinical ethics committee, says that, because the UK is a signatory to the UN Convention on the Rights of the Child, doctors must explain everything to children in a way they understand. Anyone over the age of 16 can consent to treatment, but so can younger children if doctors think they can understand and are competent to make medical decisions. Neurobiological research shows that the prefrontal cortex, home of balancing risks and rewards, is the last area of the brain to mature. So can adolescents – who are often impulsive risk-takers – be trusted to make decisions about their health? And is the AAP suggesting that we ask toddlers if they are willing to be vaccinated?
The solution
Brierley says it is good for children to understand medical decisions, as they will be more ready to make them when they are older. There is no lower legal age limit for giving consent: doctors will assess how able a child is to make a decision. And, depending on the age and the decision, they often really are able. A study of competency in making treatment decisions took people aged nine, 14, 18 and 21 and gave them hypothetical treatment dilemmas. The 14-year-olds did as well as adults. The nine-year-olds, while not understanding information as well as the adults, still made similar logical decisions.
“Most children just want to get better,” says Brierley. “If everyone thinks it’s a good thing, they will too.”
But what if a teenager doesn’t want an HPV vaccine against cervical cancer, say, because they don’t like needles? “You would tell her the benefits are clear, but you do not want to hold down a 13-year-old,” says Brierley. But it’s reasonable to immunise a toddler without going into the importance of herd immunity.
