Consent: Shared Decision-Making, Risk, Refusal and Valid Authority
Children and young people: assent, competence and parental responsibility
Children and young people should be involved in decisions about their care as much as they are able. The first clinical task is therefore not to ask only who can sign, but to explain the decision in a developmentally appropriate way, hear the young person's views and identify what they understand and want. Assent is a useful educational term for a...
Learning objectives
• Distinguish participation, assent and legally valid consent in children and young people. • Apply the broad UK principles for assessing whether a young person can make a healthcare decision while recognising jurisdiction differences. • Explain the role and limits of parental responsibility and why a young person should still be heard. • Recognise high-risk refusal and disagreement as situations that may require safeguarding, senior and legal escalation.
Participation comes before the legal label
Children and young people should be involved in decisions about their care as much as they are able. The first clinical task is therefore not to ask only who can sign, but to explain the decision in a developmentally appropriate way, hear the young person's views and identify what they understand and want.
Assent is a useful educational term for a child's positive agreement or willingness to participate when another person holds the legal authority to consent. It should not be presented as a substitute for consent, but neither should it be treated as a courtesy with no clinical significance. Resistance, distress or objection may change how the team should proceed and may require review of whether the intervention remains appropriate.
Age matters, but understanding matters too
GMC guidance states that capacity to consent depends more on a young person's ability to understand and weigh the options than on age alone. In England and Wales, section 8 of the Family Law Reform Act 1969 gives 16- and 17-year-olds statutory capacity to consent to medical, surgical or dental treatment. A person under 16 may nevertheless be competent to consent where they have sufficient maturity and understanding for the decision.
The practical error to avoid is using a birthday as the entire assessment. A straightforward low-risk intervention and a complex high-risk intervention may demand very different levels of understanding from the same young person.
Scotland is not simply the England and Wales model
Scotland has its own statutory framework. Under the Age of Legal Capacity (Scotland) Act 1991, a person under 16 can have legal capacity to consent to medical treatment when, in the opinion of the qualified medical practitioner attending them, they are capable of understanding the nature and possible consequences of the treatment. For ClinicalEdu, this means the course must label the jurisdiction rather than teaching 'Gillick competence' as a universal UK legal rule.
Parental responsibility has limits
Where a child lacks the ability to consent, a person with parental responsibility may usually provide authority for treatment within the relevant legal framework. But parental responsibility is not ownership of the child or young person's healthcare decisions. The young person's views, welfare, privacy and developing autonomy remain important.
GMC guidance advises that if parents cannot agree and the disagreement cannot be resolved informally, legal advice may be needed. Serious disputes about high-stakes treatment should not be converted into a contest of signatures.
Refusal is more complex than consent
A young person's refusal should be taken seriously. The legal position on overriding refusal differs between jurisdictions and can be more complex than the rules about giving consent. GMC guidance specifically recommends legal advice where treatment is considered to be in the best interests of a competent young person who refuses significant treatment.
The educational endpoint is therefore cautious: establish competence/capacity, understand the reasons for refusal, involve the young person, consider advocacy and safeguarding where relevant, seek senior multidisciplinary review, and obtain legal advice when necessary.
Confidentiality and safeguarding still apply
Young people may disclose information in confidence and may be reluctant to involve parents. The clinician should explain confidentiality and its limits, encourage appropriate family involvement where helpful, and recognise that serious risk of harm may justify or require disclosure. Confidentiality concerns should not be used to exclude the young person from the decision itself.
Applied scenarios
Scenario 1
A 15-year-old demonstrates a mature understanding of a proposed treatment and asks to proceed, while a parent objects.
Scenario 2
A 17-year-old refuses a potentially life-saving intervention after a detailed discussion; the team assumes adult refusal rules apply without qualification.
Scenario 3
A clinician uses an England and Wales consent leaflet for an under-16 patient in Scotland without checking the Scottish statutory framework.
Practice checklist
- Explain the decision directly to the child or young person in a form they can understand.
- Assess understanding in relation to the specific decision rather than using age alone.
- Identify who has legal authority and which UK jurisdiction applies.
- Hear and record the young person's views even where another person provides legal consent.
- Treat serious refusal or unresolved disagreement as a trigger for senior, safeguarding and legal review.
- Recheck current local policy and law before acting in complex paediatric disputes.
