{"id":4073,"date":"2020-12-23T02:19:02","date_gmt":"2020-12-23T01:19:02","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4073"},"modified":"2020-12-23T02:43:51","modified_gmt":"2020-12-23T01:43:51","slug":"bell-v-tavistock-and-portman-nhs-foundation-trust-considering-the-potential-impact-on-childrens-consent-to-all-medical-treatment","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/12\/23\/bell-v-tavistock-and-portman-nhs-foundation-trust-considering-the-potential-impact-on-childrens-consent-to-all-medical-treatment\/","title":{"rendered":"Bell v Tavistock and Portman NHS Foundation Trust: Considering the potential impact on children\u2019s consent to all medical treatment?"},"content":{"rendered":"<p>By Rebecca Limb and Liz James<\/p>\n<p>On 1st December 2020, the <a href=\"https:\/\/www.judiciary.uk\/wp-content\/uploads\/2020\/12\/Bell-v-Tavistock-Judgment.pdf\">Tavistock judgment<\/a> was published. The legal issue concerning the court was identifying the circumstances where a child, under the age of 18 diagnosed with Gender Dysphoria (GD), is competent to give valid consent to the administration of puberty blockers (PB).<\/p>\n<p>The judgment has made no substantial change to the law. <a href=\"https:\/\/www.legislation.gov.uk\/ukpga\/1969\/46\">Children aged 16 and 17 are presumed to have capacity to consent to medical treatment<\/a> and children under the age of 16 must be <a href=\"http:\/\/www.hrcr.org\/safrica\/childrens_rights\/Gillick_WestNorfolk.htm\"><em>Gillick<\/em> competent<\/a> &#8211; demonstrate sufficient understanding and intelligence of the proposed treatment \u2013 to provide valid consent.<\/p>\n<p>The Gender Identity Development Service (GIDS) took great care to assess children\u2019s competency to consent, ensuring children are fully informed of all the known and unknown risks of PB\u2019s and are individually assessed. Concerning the judges was the year on year increase of children in all age groups being considered <em>Gillick<\/em> competent and subsequently prescribed PB, and the lack of statistical data on children\u2019s competency when referred to the GIDS.<\/p>\n<p>Expressing distrust in the accuracy and validity of the <em>Gillick<\/em> competency assessments conducted by GIDS\u2019s, the judges created three guidelines.<\/p>\n<p>First, to satisfy <em>Gillick,<\/em> children must be informed of all the known and unknow risks of PB AND the risks associated with cross-sex hormones (CSH) and potential gender reassignment surgery (GRS).<\/p>\n<p>Although the first step for patients who wish to receive medical treatment, PB are a distinct treatment that does not require a child to progress to CSH or GRS.<\/p>\n<p>In medical law, <a href=\"https:\/\/www.bma.org.uk\/media\/2481\/bma-consent-toolkit-september-2019.pdf\">it is well established that consent is required for every medical intervention.<\/a><\/p>\n<p>Consent for one intervention is not valid consent for another. Requiring children to be fully informed of the risks of CSH and GRS before taking PB is akin to requiring a patient to be fully informed of the risks posed by open heart surgery before taking oral medication for a progressive heart condition.<\/p>\n<p>Whilst it is likely the doctor will recommend surgery to a patient with a progressive heart disease in the future, the patient does not need full understanding of heart surgery to demonstrate competency to consent to take medication.<\/p>\n<p>A child should be aware of Dr Carmichael\u2019s statistics <a href=\"https:\/\/www.judiciary.uk\/wp-content\/uploads\/2020\/12\/Bell-v-Tavistock-Judgment.pdf\">that 55% of children on PB progress to further treatment<\/a>, but it is deeply concerning that a child must provide informed consent to a distinct treatment they may never have before being prescribed PB. If legally binding, this would have far-reaching consequences for the law of consent.<\/p>\n<p>Second, the court introduced a \u2018competency framework\u2019. Based on evidence from experts in child cognitive development, the judges consider it highly unlikely that children under 13 would ever be <em>Gillick <\/em>competent to consent to PB and are \u201c<a href=\"https:\/\/www.judiciary.uk\/wp-content\/uploads\/2020\/12\/Bell-v-Tavistock-Judgment.pdf\">very doubtful<\/a>\u201d that 14- and 15-year olds could satisfy Gillick and consent to PB. With regards to 16- and 17-year olds, <a href=\"https:\/\/www.legislation.gov.uk\/ukpga\/1969\/46\">English Law presumes they have capacity to consent to PB<\/a>.<\/p>\n<p>Third, further demonstrating distrust in doctors <em>Gillick<\/em> assessments, because puberty blockers have unknown consequences and are considered innovative and experimental, GIDS may consider seeking the court\u2019s authorisation prior to commencing treatment.<\/p>\n<p>In direct response, <a href=\"https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2020\/12\/Amendment-to-Gender-Identity-Development-Service-Specification-for-Children-and-Adolescents.pdf?fbclid=IwAR0yV_Ukyr0oDsjrB11As10tpqHP15bvrxjqGSY8kFn-MxQsfKmsf2X4Fus\">GIDS changed their protocols<\/a> requiring that all patients under 16 must not be referred by GIDS for PB unless a \u2018best interests\u2019 order has been made by the court for that specific child. This demonstrates a clear reluctance from doctors to administer PB without the court\u2019s authorisation. We must question whether these guidelines breach the Equality Diversity Act 2010, where children experience barriers to medical treatment because of their protected characteristic.<\/p>\n<p>This judgment also calls into question the validity of <em>Gillick<\/em> competency assessments conducted in all children\u2019s hospitals, for all conditions. If we do not have confidence in how <em>Gillick<\/em> competency is assessed, how can we be sure that a child\u2019s consent to ANY treatment is valid?<\/p>\n<p>Could the reluctance seen by GIDS to administer medical treatment based solely on a <em>Gillick<\/em> child\u2019s consent extend to all areas of innovative or experimental medicine with some unknown risk? A consequence of this judgment is an over reliance on parental consent in all areas of medicine, reducing the power of child\u2019s consent to tokenism. In doing this we diminish the autonomy of children and remove a crucial element in their development to maturity.<\/p>\n<p><strong>Authors:<\/strong> Rebecca Limb and Liz James<\/p>\n<p><strong>Affiliations:<\/strong> University of Warwick and NCC Group&#8217;s LGBTQIA+ steering committee<\/p>\n<p><strong>Competing interests:<\/strong> None declared<\/p>\n<p><strong>Social media accounts of post author(s<\/strong>): \u00a0\u00a0Rebecca Limb (<a href=\"https:\/\/warwick.ac.uk\/fac\/soc\/law\/people\/rebecca_limb\/\">https:\/\/warwick.ac.uk\/fac\/soc\/law\/people\/rebecca_limb\/<\/a>)<\/p>\n<p>Liz James (<a href=\"https:\/\/www.nccgroupplc.com\/careers\/inclusion-diversity\/lgbtqia\/\">https:\/\/www.nccgroupplc.com\/careers\/inclusion-diversity\/lgbtqia\/<\/a> )<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Rebecca Limb and Liz James On 1st December 2020, the Tavistock judgment was published. The legal issue concerning the court was identifying the circumstances where a child, under the age of 18 diagnosed with Gender Dysphoria (GD), is competent to give valid consent to the administration of puberty blockers (PB). The judgment has made [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/12\/23\/bell-v-tavistock-and-portman-nhs-foundation-trust-considering-the-potential-impact-on-childrens-consent-to-all-medical-treatment\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":353,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-4073","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Bell v Tavistock and Portman NHS Foundation Trust: Considering the potential impact on children\u2019s consent to all medical treatment? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2020\/12\/23\/bell-v-tavistock-and-portman-nhs-foundation-trust-considering-the-potential-impact-on-childrens-consent-to-all-medical-treatment\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Bell v Tavistock and Portman NHS Foundation Trust: Considering the potential impact on children\u2019s consent to all medical treatment? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Rebecca Limb and Liz James On 1st December 2020, the Tavistock judgment was published. 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