Lowering the age of consent: Legal, ethical, and clinical implications of adolescent-directed therapy
Special Feature
Kathleen McNamara
Family Court Review, 8 June 2023
Abstract
This article discusses a recently enacted Colorado law that aims to reduce the youth suicide rate by lowering the age of consent for psychotherapy from age 15 to age 12. The author discusses the challenges therapists face when young adolescents seek therapy without parental consent in cases involving interparental conflict. Suggestions for managing adolescent-directed therapy are offered.
Consent in minors: the differential treatment of acceptance and refusal. Part 1 Autonomy and children’s rights
Consent in minors: the differential treatment of acceptance and refusal. Part 1 Autonomy and children’s rights
Tim Hawkins, Martin Curtice, Tom Adams
BJPsych Advances, 5 June 2023
Summary
This is the first of two articles reviewing consent in those under the age of 18 (also referred to as ‘minors’ in UK law). This can be a complex issue in clinical practice because the law endows competent/capacitated minors with the absolute right to accept treatment, but a limited right to refuse. This first article summarises recent cases of refusal of treatment in minors. It uses them to ask two central questions: how do we, as clinicians, think about autonomous self-determination in minors and to what extent does the rights agenda support minors’ autonomous self-determination? Autonomy as one of the principles of biomedical ethics is explored. How the minors’ rights agenda supports the development of autonomy is considered. The amount of weight given in the domestic courts to the rights of minors with reference to the Human Rights Act 1998 and the United Nations Convention on the Rights of the Child is described. These considerations demonstrate the way that the courts are giving the views of the minor greater weight in decision-making in keeping with age and maturity. This article introduces the second article, which comprehensively reviews decision-making in minors, explores competence and capacity in minors and examines the differential treatment of acceptance and refusal.
Editor’s note: BJPsych Advances distils current, peer-reviewed, clinical knowledge dealing with physical and biological aspects of treatment, psychological and sociological interventions, management issues and treatments specific to the different psychiatric subspecialties.
Consent in minors: the differential treatment of acceptance and refusal. Part 2 Minors’ decision-making and the reach of their capacity
Consent in minors: the differential treatment of acceptance and refusal. Part 2 Minors’ decision-making and the reach of their capacity
Tim Hawkins, Martin Curtice
BJPsych Advances, 5 June 2023
Summary
This is the second of a pair of articles reviewing the topic of consent in minors. Both articles have a particular emphasis, drawing on theory and case law, on the differential treatment of acceptance and refusal in minors. This article considers the concept of capacity in young people (aged 16 and over) and competence in children (under the age of 16) by reviewing underpinning statute and case law with particular reference to England and Wales. This provides a platform for consideration of the reach of capacity in minors with regard to acceptance and refusal of treatment. In doing so the article explores the key, but still elusive, ingredient of maturity, which has significance to the process. Fictitious vignettes allow consideration of the application of the concepts of maturity and autonomy in clinical practice. The article also considers the potential for the UK’s Parliament to make changes to current statute regarding consent in minors.
Research ethics committee members’ perspectives on paediatric research: a qualitative interview study
Research ethics committee members’ perspectives on paediatric research: a qualitative interview study
Kajsa Norberg Wieslander, Anna T Höglund, Sara Frygner-Holm, Tove Godskesen
Research Ethics, 2023
Abstract
Research ethics committees (RECs) have a crucial role in protecting children in research. However, studies on REC members’ perspectives on paediatric research are scarce. We conducted a qualitative study to explore Swedish scientific REC members’ perspectives on ethical aspects in applications involving children with severe health conditions. The REC members considered promoting participation, protecting children and regulatory adherence to be central aspects. The results underscored the importance of not neglecting ill children’s rights to adapted information and participation. REC members supported a contextual and holistic approach to vulnerability and risk, which considers the child’s and parents’ psychological wellbeing and the child’s integrity, both short and long term. The ethical complexity of paediatric research requires continuous ethical competence development within RECs.
Applications of Extended Reality (XR) in obtaining informed consent: A narrative review
Applications of Extended Reality (XR) in obtaining informed consent: A narrative review
Research Article
Michelle Lai, Rob (Hongbo) Chen, Andrew Evanyshyn, Zeina Shaltout, Myrtede Alfred
Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care, 7 June 2023
Abstract
Informed consent in healthcare requires patients to have a sufficient understanding of their upcoming procedure before deciding to proceed. Unfortunately, education prior to a surgical procedure is constrained by barriers including poor health literacy, language barriers, one-sided dialogue during consultations, anxiety, and knowledge retention. Extended reality (XR), which includes virtual reality (VR), augmented reality (AR), and mixed reality (MR) has the potential to improve informed consent processes by creating an immersive, interactive, and multimodal sensory experience that supports patient education. The purpose of the study was to review the extant literature on the effectiveness of XR technology in improving patient education, a vital component of informed consent. We screened fifty-two articles and ten relevant papers from PubMed, Scopus, and Compendex, which were included in the review based on our eligibility criteria. We found that VR and AR proved effective in enhancing patient education in eight studies, and thus improving informed consent processes. MR was not utilized in the studies reviewed. The studies were conducted in several countries and positives findings were reported from a broad range of clinical settings and procedures. Though further investigation is needed, this is a promising finding that may encourage health systems to implement similar interventions prior to procedures. The review also provided an overview of the existing XR technology utilized for patient education such as a downloadable mobile application with a virtual chatbot character, and an environment designed to simulate the MRI patient’s perspective. These applications provide immersive and interactive experiences when paired with a head mounted headset such as Google VR Cardboard. The findings also revealed that XR tools are customizable and can be tailored to specific surgical procedures, which makes the potential of implementation applicable to a broader range of settings.
Beyond translations, perspectives for researchers to consider to enhance comprehension during consent processes for health research in sub-saharan Africa: a scoping review
Beyond translations, perspectives for researchers to consider to enhance comprehension during consent processes for health research in sub-saharan Africa: a scoping review
Nkosi Busisiwe, Janet Seeley, Ann Strode, Michael Parker
BMC Medical Ethics, 21 June 2023; 24(1) pp 1-16
Open Access
Abstract
Background
Literature on issues relating to comprehension during the process of obtaining informed consent (IC) has largely focused on the challenges potential participants can face in understanding the IC documents, and the strategies used to enhance comprehension of those documents. In this review, we set out to describe the factors that have an impact on comprehension and the strategies used to enhance the IC process in sub-Saharan African countries.
Methods
From November 2021 to January 2022, we conducted a literature search using a PRISMA tool. We searched electronic databases (PubMed, EMBASE, EBSCOHOST) to identify relevant peer reviewed studies. We then reviewed the references of these articles to find additional literature that might have been missed through the initial search. We were particularly interested in full text articles in English that focused on the IC process in SSA published between 2006 and 2020. We included systematic reviews, and studies from Western and Asian countries that included data about SSA. We excluded articles that focused on medical interventions and studies that did not require IC.
Results
Out of the 50 studies included most were multi-country (n = 13) followed by single country studies in South Africa (n = 12); Kenya, Tanzania, Uganda (n = 5) each; Gambia, Ghana and Nigeria (n = 2)each ; and one each for Botswana, Malawi, Mali, Mozambique. We identified three areas of focus: (1) socio-cultural factors affecting IC; (2) gaps in the ethical and legal frameworks guiding the IC process; and (3) strategies used to improve participants’ understanding of IC.
Conclusion
Our review showed wide recognition that the process of achieving IC in SSA is inherently challenging, and there are limitations in the strategies aimed at improving comprehension in IC. We suggest that there is a need for greater flexibility and negotiation with communities to ensure that the approach to IC is suited to the diverse socio-cultural contexts. We propose moving beyond the literal translations and technical language to understanding IC comprehension from the participants’ perspectives and the researchers’ views, while examining contextual factors that impact the IC process.
A survey on current practice of informed consent process in surgical specialties of a Portuguese tertiary teaching hospital center: What is the state of play?
A survey on current practice of informed consent process in surgical specialties of a Portuguese tertiary teaching hospital center: What is the state of play?
Original Article
A.L. Vieira, C. Infante, S. Santos, M. Asseiro, C. Ferreira
Ethics, Medicine and Public Health, June 2023
Open Access
Summary
Background
Informed consent is essential in current medical practice and should be a gold standard to be sought in all instances when doctors interact with patients. The aim of this study was to evaluate compliance to the guidelines of the Portuguese health entity regarding the correct filling process of informed consent.
Methodology
An audit was conducted at the operating rooms of a tertiary teaching hospital center in Portugal, in March 2021, in order to verify the presence of informed consent in the clinical file of surgical patients. A representative cohort of 202 clinical files was collected.
Results
An informed consent document was found in only 47% of the clinical files. Merely 21.8% of the informed consent documents included all the items recommended by the guidelines of the Portuguese health entity. Most of these informed consent documents (SIC) included only basic information, with only a small minority including reports about the surgical procedure, information regarding treatment, possible consequences of a missed treatment or complications and possible treatment alternatives. These results do not conform to the standard regulations of the Portuguese health guidelines regarding SIC.
Conclusion
Even though improvements in SIC were attained in recent years, our study suggests that the implementation of SIC is still suboptimal in surgical practice. It is important to raise awareness for the obtention of SIC by the healthcare team, given the ethical importance of such a document in the context of any invasive procedure.
Deception and informed consent in studies with incognito simulated standardized patients: empirical experiences and a case study from South Africa
Deception and informed consent in studies with incognito simulated standardized patients: empirical experiences and a case study from South Africa
Original Article
Benjamin Daniels, Jody Boffa, Ada Kwan, Sizulu Moyo
Research Ethics, 22 May 2023
Open Access
Abstract
Simulated standardized patients (SPs) are trained individuals who pose incognito as people seeking treatment in a health care setting. With the method’s increasing use and popularity, we propose some standards to adapt the method to contextual considerations of feasibility, and we discuss current issues with the SP method and the experience of consent and ethical research in international SP studies. Since a foundational discussion of the research ethics of the method was published in 2012, a growing number of studies have implemented this method to collect data on the quality of care in a variety of settings around the world. We draw from that experience to provide empirical foundations for a popular approach to ethical approval of such studies in the United States and Canada, which has been to obtain a waiver of informed consent from the health care providers who are the subjects of the research. However, the majority of studies to date have evaluated quality of care outside the U.S., requiring additional ethical consideration when partnering with international institutions. We discuss these considerations in the context of a case study from a completed SP study in South Africa, where informed consent is constitutionally protected.
Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands
Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands
Original Research
Marit Sophia Gerardina van der Pijl, Margot Klein Essink, Tineke van der Linden, Rachel Verweij, Elselijn Kingma, Martine H Hollander, Ank de Jonge, Corine J Verhoeven
BMJ Quality & Safety, 22 May 2023
Abstract
Background
Informed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter.
Methods
A national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting.
Results
13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54–0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting.
Conclusions
Consent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman’s refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.
Judging in a Brave New World?: Adjudicating Cases of Parental Refusal on Religious Grounds to Consent to Medical Treatment
Judging in a Brave New World?: Adjudicating Cases of Parental Refusal on Religious Grounds to Consent to Medical Treatment
Michelle Flynn
Journal of Law, Religion and State, 15 June 2023
Abstract
This article considers case law concerning parental refusal to consent to medical treatment of a child based on religious belief or conscience. The focus of enquiry is on three pivotal decisions of the Irish Superior Courts which will serve to chart the development of judicial reasoning in this contentious area of law. In the last few decades, Ireland has experienced significant changes in its population and attitudes toward religion as a result of increased immigration, multiculturalism, and secularism. This case law analysis reveals that there has been a shift from a test that examines the motivations or reasons for parental decision making to one that focuses on the effect on the child. This shift in focus raises concern about the extent to which the religious or conscientious objection of a parent concerning a child’s medical treatment will be considered in future cases. The present analysis provides an illuminating example of the way in which religion and the state can be in tension with each other.
Center for Informed Consent Integrity 