You are a GP and you see Millie, a fifteen year old who comes alone. She tells you that she would like to go on the pill. What issues does this raise? How would you handle this scenario? Answer
Millie should be asked why she wants to go on the pill. The pill is often used for other conditions, such as to regulate and control periods and treat acne but it is likely that she is requesting it because she wishes it to be used as a contraceptive.
Using the 4 ethical pillar framework [see P74-79 Medical School Interviews – The Knowledge ]
What does the law say? [Justice]
Millie is fifteen; younger than the age of consent [16yrs]. Her parents are almost certainly her legal guardians. If she is having sex with a man over the age of 18 that man can be accused for child abuse as she is still legally a child. However see the Fraser Ruling below on contraceptive prescribing.
Beneficence – A doctor should always act in the patient’s best interests.
Sex before the age of consent is common in this country and the rate of teenage pregnancies and sexually transmitted diseases in the UK is higher than in any other European country. Millie has shown that she can be responsible by seeing her doctor. It is important for the doctor to establish a good relationship with Millie, to be someone she feels she can trust. Millie is more likely to take the doctor’s advice regarding protecting herself against sexually transmitted disease by using condoms if she feels that she is not misunderstood and patronised. If Millie is going to have sex anyway it would be in her best interest that the risk of pregnancy and sexually transmitted diseases is minimised.
There is no evidence that prescribing contraception increases teenage sexual intercourse levels – however this is contentious. Evidence exists to show that good contraceptive access decreases teenage pregnancies. The side effects of the pill are usually minor and serious side effects rare in most girls but risk factors need to be screened for by the doctor.
Under the Gillick Ruling and Fraser Rules if Millie can demonstrate that she understands the risks of sex at such a young age and the risks of treatment with the pill then she has competence and therefore autonomy. The Fraser rules [see below] state that the doctor should question Millie to see if she has full understanding and try and persuade her to involve her parents. However if she is adamant that she does not want them to know then she has the right to confidentiality. If the doctor feels that there is a strong likelihood of sex occurring any way then he should prescribe her contraception.
Fraser Ruling and Gillick Competence
Mrs Gillick took her Health Authority to court because they were supplying contraceptives to under 16yr olds without informing parents. She had 5 daughters and felt that she had a right to know if they were being prescribed anything.
The case went to the House of Lords. The judges, chaired by Lord Fraser, ruled that if a child was competent and had autonomy then their confidentiality was to be respected [i.e. their parents did not need to be informed] if they fully understood all the risks. The doctor should try to persuade the child to talk to her parents but if the child insisted she did not want to, they did not need to be informed. In the case of contraception the doctor had to feel that there was a strong likelihood of sex occurring anyway. The doctor should always consider the possibility of sexual abuse [which should be always reported].
This case led to the term Fraser Rules and Gillick competence.
A child is ‘Gillick Competent’ if he/she is mature enough to have understanding of what is involved – there is no arbitrary age limit.
These rules apply to all medical procedures not just contraception and abortions. A ‘Gillick competent’ child can give consent to have a procedure against the wishes of her/his parents and has the right to confidentiality. (see earlier ethical scenario on The Jehovah Witness Boy)