Joumal of Advanced Nursing, 1995,21,623-624
Guest editorial
LISTENING TO CHILDREN: MEDICAL
TREATMENT AND CONSENT
At the age of 16, somethmg magical happens as far as the
health service m the Umted Kingdom is eoneemed Few
people feel any different, even fewer are nobeeahly differ-
ent m themselves, yet this is a most important milestone
m a person's life One reason for this is that it is at the age
of 16 that a young person is considered capable of giving
informed consent to medical treatment
Many of those who heheve that age really has little to
do with a person's ahility to understand and consent to
treatment had great hopes that the Children Act 1989
would really ehange this lnflexihility, m praebee this
seems to be the exeepbon rather than the rule A number
of well worn arguments ean be put against involving ehil-
dren in deeisions ahout their eare, rangmg from develop-
mental theories through to eoneems ahout their lack of
ability to comprehend the gravity of important decisions
A lack of research and expenenee m this area compounds
the prejudiees of many health care staff who heheve that
children are incapable of giving consent
One area m which quite a lot of work has heen done is
m looking at the ability of children to take part in decisions
regarding terminal care, albeit much of it from the United
States Nitschke et al (1982) found that children as young
as 5 years old with terminal eaneer were able to take
deeisions about future therapy versus supporbve eare vwth
or without parental involvement They put this issue to
the ehildren very bluntly, but as KUbler-Ross (1991)
demonstrates, there are ways of explaining even eomplex
issues like death in a ehild-fnendly way She eompares
the d5nng ehild to a eoeoon enveloping a hutterfiy, which
emerges at the point of death leavmg the eoeoon to be
buried and conbnmng its existence elsewhere This is
important not just because of this example, useful though
It IS, hut because it demonstrates the importance of finding
fnendly and mnovabve ways of explammg situabons to
ehildren
In many ways, although the subjeet is diffieult, speeialist
paediatne nurses workmg m sueh areas have a distmet
advantage when involving the ehild in giving eonsent
They will usually know the child and family well and vinll
have had the opportumty to bmld up a trustmg relabon-
ship with the family Nurses m aeute or general setbngs
will not neeessanly have this luxury, and the ehildren will
not always have had the elose eontact with hospitals and
staff that eontnhuted to the inereased awareness of the
children that Nitschke et al (1982) spoke to
Although ohtammg informed consent for medical pro-
cedures IS a job for medicad staff, nurses have an important
role, through the umque relabonship hetween child,
family and nurse, to ensure that the child's views are con-
sidered Alderson (1990) eites an mteresbi^ ai^ument
hased on the Scottish law of moral responsibility from a
lawyer. Sheila MeLean, who suggests that the competence
of the decision made should he the issue rather than the
age of the person making that decision This would mean
that the onus would he on the adults to justify non-
mvolvement of the child m consent and decision making
Although this sounds like a radical proposal at first, it
simply asks that adults give children the same respect that
they themselves expect It is mteresbng to consider how
many decisions made by adults about medical treatment
are made by people who truly understand the conse-
quences of the decisions that they are making
One reason why children are not yet fully involved in
their care may he that the Children Act 1989 states that it
IS the doetor's responsibility to deeide if the ehild has the
eapacity to understand the nature of the treatment Quite
how doctors are expected to reach this decision is not
clear Of eourse, it would he mee to think that they dis-
eussed this with parents, ehildren and other health care
professionals who eould then reach agreement The folly
of competence tests are discussed by Alderson (1990) who
points out that not only are these suhjective hut they often
ask children to show greater levels of competence than the
average adult
As well as a lack of elanty about how to deeide whieh
ehildren are eompetent, a lot of doctors who will he
making these decisions will have relabvely little expen-
ence of working with children, especially in local general
hospitals where many children are sbll looked after hy
surgeons canng mamly for adult pabents The implication
of this IS that sick children need a powerful advocate to
ensure that their views are eonsidered, a role that
would ideally be undertaken by a parent or guardian
Unfortunately, there are many reasons why this may not
be possible, and many parents feel unable to argue with
well edueated doetors who appear to have authonty on
their side It may also be the ease that some parents do not
see the need for their ehild to have a say in deeisions about
their own treatment, and while this situabon ohviously
requires sensibve handling it is important that the ehild
IS allowed to express an opinion and feel that this opimon
IS valued Because paediatnc nurses may be the most
expenenced people mvolved m the care of the child, they
should he closely involved in these discussions and
decisions alongside the other interested parties
It IS important that the nurse is ahle to act as an advocate
on behalf of the child, yet lack of knowledge, poor
communicabon skills and the tradibonal subservience of
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 Guest editonal

nurses to doctors all make this less likely (Chambers 1992)
It also takes a lot of courage to stand up against the estab-
lishment and perceived wisdom, be this m the form of
parents, doctors or other nurses
The real answer to this difficult problem lies deeper in
society We need to leam to respect children just as we do
adults, both m regard to medical care and generally
Crompton (1992) suggests that we need to consider chil-
dren as complete entities rather than simply immature
adults She also advocates a movement for 'childism', just
as some people advocate femimsm, so that we leam to
value children for what they are and not just what they
will become Part of tbis process of leaming to value chil-
dren IS to value then: views and opimons, even though it
IS difficult to think of values that are more fundamental
than those embodied in the principle of informed medical
consent by children
References
Alderson P (1990) Choosing for Children Oxford Umversity
Press, Oxford
Chambers M (1992) Who speaks for the children'' Joumal of
Clinical Nursing 1(2), 73-76
Children Act 1989 An Introductory Guide for the NHS (1992)
HMSO, London
Crompton M (1992) Children and Counselling Edward Arnold,
London
KUbler-Ross E (1991) The dymg child In Children and Death
(Papadatou D & Papadatos C eds). Hemisphere, New York,
pp 147-160
Nitschke R, Humphrey B , Sexauer C , Catron B , Wimder S &
Jay S (1982) Therapeubc choices made by pabents with end
stage cancer foumal ofPediatncs 101(3), 471-476

Edward Purssell
RGN RSCN
Staff Nurse, Host Defence Umt,
Great Ormond Street Hospital for Children NHS Tmst,
London WClN 3fH, England

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