Gillick Competence and Fraser Guidelines – UK Medicine Ethics and Interview Questions

Aspiring medical students need to be prepared to discuss hot topics like medical ethics during their medical school interview.

The case of Gillick v West Norfolk and Wisbech Area Health Authority [1986] is an important legal case for students to be aware of when preparing for medical school interviews.

Two key concepts stem from this case – Gillick competence and Fraser guidelines.

This article will outline and explain these concepts, and then lead you through how they can be applied in medical school interviews.

Combine your reading here of medicine interview questions and model answers with medicine interview tutoring or 1-1 mock interviews to boost your answers and delivery.

Gillick Competence and Fraser Guidelines for Medical Interviews: A Summary

1. A child is deemed Gillick competent if they are under 16 years of age and are understood to be intelligent and mature enough to fully understand the medical treatment/procedure that is proposed by a healthcare professional
2. Fraser guidelines demonstrate when it is allowed for health professionals to give advice relating to contraception/sexual health to children under the age of 16
3. The concepts of Gillick competence and Fraser guidelines come directly from the case of Gillick v West Norfolk and Wisbech Area Health Authority [1986]
4. Gillick competence and Fraser guidelines do not apply to children who are 16 or 17 years old
5. It is important for you to have a good understanding of these concepts prior to your interview(s) as they are at the core of paediatric medical practice in the UK

What was the Gillick case? (Gillick v West Norfolk 1985)

A mother named Victoria Gillick believed it to be unlawful that children under the age of 16 (the age of consent to sexual intercourse in the UK) could seek contraceptive advice from their GP without parental knowledge or consent.

She, therefore, approached the courts to challenge the Department of Health guidance that allowed this practice. The case ended up at the highest court in England at that time, the House of Lords.

Ultimately, Victoria Gillick was unsuccessful, and instead, Gillick competence and Fraser guidelines were produced and defined.

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What is Gillick competence?

What are the criteria for Gillick competence?

There is no fixed checklist, but when assessing whether an under-16 is Gillick competent a healthcare professional considers the child's intelligence and maturity, their previous experience of healthcare, and whether they can understand the proposed treatment, weigh up its pros and cons, and grasp how it will affect their life. Crucially, the assessment is made for each individual decision rather than from the child's age alone.

A child can be referred to as Gillick competent if:

• The child is under 16 years of age

AND

• The healthcare professional deems the child intelligent and competent enough to fully understand the treatment/medical decision being proposed

A child can be deemed Gillick competent for one decision and not another because different medical decisions require different levels of intelligence and maturity in order to be understood.

For example, a child could be considered competent to consent to the prescription of anti-allergy medication, but incompetent to consent to a complex medical procedure.

If a child is not deemed to be Gillick competent by the healthcare professional dealing with their care, a parent or guardian must give consent in the child’s place for treatment/medical procedures.

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How is Gillick competence assessed?

There is no one test to apply to a child to understand whether they are Gillick competent or not. Instead, various factors are taken into consideration to understand the child’s competence. For example:

The intelligence and maturity of the child

• This is usually gauged through discussion with the child

The child’s previous experiences

• For example, the child may have lots of experience in healthcare settings and thus may be more likely to understand a procedure because they have seen it performed before

The ability of the child to understand the treatment/procedure, whether they can weigh the pros and cons and understand how it will affect their life

• This can be clarified by asking the child questions about the treatment/procedure

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What are the Fraser guidelines?

Fraser guidelines also stem from Gillick v West Norfolk and Wisbech Area Health Authority [1986], as they are named after one of the judges in the case. These guidelines relate only to contraception and sexual health of children under the age of 16.

The Fraser guidelines set out in the case in 1986 only related to contraceptive advice and treatment, however, these guidelines now relate also to general sexual health decisions (like treating STIs) and termination of pregnancy.

The guidelines demonstrate when it is allowed to give sexual health advice/treatment to children under the age of 16. It is permissible if:

• The child is mature and intelligent enough to understand the treatment proposed
• The child cannot be persuaded to tell their parents/guardian or let the doctor tell them
• The child is likely to start having or continue having, sexual intercourse with or without contraception
• The mental or physical health of the child is likely to suffer without the advice/treatment
• It is in the best interests of the child to receive the advice/treatment

The healthcare professional must not break confidentiality if the Fraser guidelines are applied appropriately – they cannot contact the parent or guardian of the child regarding their sexual health or contraception.

However, if the healthcare professional believes the child is being harmed or is at risk of being harmed, they can break confidentiality in order to inform social services/police. It is important that the child is informed that confidentiality is being broken.

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What is the difference between Gillick competence and Fraser guidelines?

While both principles are aimed at assessing a child's capacity to consent to medical treatment, the key difference is their area of application.

Gillick competence can be applied to any medical treatment or procedure.

Fraser guidelines, on the other hand, specifically apply to advice or treatment regarding contraception and sexual health.

Gillick competence and Fraser's guidelines frequently get confused with one another. However, in interviews, it is important that you are clear on which term is which.

One way to remember how the terms differ is by remembering that Gillick is more GENERAL (it can be applied to children with regard to ANY medical decision).

Fraser guidelines are more FOCUSED (they only apply to contraception and sexual health).

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What about 16 and 17-year-olds? Does Gillick competence apply?

Can a Gillick competent child refuse treatment?

Being Gillick competent allows an under-16 to consent to treatment, but it does not give them an absolute right to refuse it. Where a competent child or a 16 to 17-year-old refuses treatment that is needed to prevent serious harm, a person with parental responsibility or a court can override that refusal if doing so is in the child's best interests. This reflects the principle that the child's welfare is the paramount consideration in English law.

16 and 17-year-olds are also children according to English law, however, the law regards them as having the capacity to consent to medical treatment as if they are adults.

However, if a 16 or 17-year-old refuses to give consent for treatment, a parent or guardian can override their refusal and provide consent on behalf of the child instead.

The welfare of the child concerned is the main consideration in English law, and this is demonstrated by ensuring that 16 and 17 years do not have the absolute right to refuse treatment that would be in their best interests.

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Ethical Considerations of Gillick Competence and Fraser Guidelines

It is common in medical school interviews to be asked about ethical considerations of certain concepts or situations that arise in medicine. Therefore, it is important to understand the ethical considerations that apply to Gillick's competence and Fraser's guidelines.

• Autonomy: Autonomy is both advocated for and restricted by Gillick's competence and Fraser's guidelines. The autonomy of competent children is respected when Gillick's competence and/or Fraser's guidelines are applied. However, parents/guardians are deprived of their autonomy over their children.
• Beneficence/non-maleficence: These are important considerations when looking at Gillick competence and Fraser guidelines. Health professionals want to respect the autonomy of competent children, but also maintain that this is balanced with ensuring that no harm comes to the child. This is why it is so important to ensure that children’s competency is assessed for every medical decision, and is not assumed.
• Justice: When assessing the competency of a child, it is important that it is done fairly. Just because a child is 15 years old, does not mean they are automatically competent to make a medical decision. Furthermore, a 13-year-old is not automatically unable to make a medical decision for themselves.

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Example: Applying Gillick Competence in a Primary Care Setting

Imagine a situation where a 14-year-old boy, Sam, visits his general practitioner (GP) seeking treatment for severe acne. The GP suggests a prescription for a powerful acne medication that is generally safe but has some potential side effects including mood changes and liver problems.

According to the principle of Gillick competence, the GP would need to assess whether Sam is capable of fully understanding the proposed treatment and its potential implications. They may do this by asking Sam a series of questions about the medication, its side effects, and why it's being proposed, to gauge Sam's understanding of the situation.

For instance, the GP could ask: "Can you tell me in your own words why you think I am suggesting this medication for you?" or "What do you understand about the possible side effects of this medication?"

If Sam demonstrates an understanding that the medication will likely improve his acne, but also comes with potential risks, the GP could consider him Gillick competent to consent to this treatment. This decision is made on the basis of Sam's understanding and maturity, rather than his age.

The GP should also consider discussing the medication with Sam's parents, especially given the potential serious side effects. However, if Sam explicitly states he does not want his parents involved and the GP determines he is Gillick competent, then the GP must respect Sam's privacy.

This scenario highlights how Gillick competence can be applied in practice and underscores the importance of individual assessments of minors when it comes to their healthcare decisions.

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Legal Consequences of Non-Adherence to Gillick Competence and Fraser Guidelines

Understanding and applying Gillick Competence and Fraser Guidelines is not only a moral responsibility for healthcare professionals but also a legal requirement in the UK.

Non-adherence can lead to serious legal implications that may affect all parties involved - the healthcare professional, the child, and their parents.

For Healthcare Professionals: The failure to assess a minor's Gillick competence or to correctly apply the Fraser guidelines can have severe professional consequences. Medical professionals could face disciplinary action from their professional body, such as the General Medical Council, potentially leading to loss of licensure or legal actions including negligence claims.

It is therefore crucial that healthcare professionals handling child patients understand the principles of Gillick competence and the Fraser guidelines. The correct application of these guidelines forms an essential part of patient safety and risk management in child healthcare.

For Minors (Under 16): In a scenario where a child's Gillick competence isn't correctly assessed, the child may receive treatment or care they don't fully understand or consent to, which may lead to unwanted physical or psychological consequences.

It is essential that healthcare providers follow Gillick's competence and Fraser's guidelines to uphold the rights of the child, ensuring they receive suitable healthcare.

For Parents: Parental rights and responsibilities can also be affected if these guidelines are not properly adhered to. The failure to correctly apply Gillick competence may infringe on a parent's right to provide informed consent for their child’s treatment if the child is deemed not competent. Similarly, it could bypass a parent's involvement in their child's healthcare decisions when they should be consulted.

In summary, compliance with Gillick's competence and Fraser guidelines isn't just an ethical necessity, but also a legal requirement to protect healthcare professionals, parents, and most importantly, the child's rights in the healthcare setting.

Being well-versed in the application of these guidelines will prevent potential legal disputes, promote high-quality patient care, and uphold medical ethics in paediatric healthcare practice and in your medicine interview.

Preparing for a medicine interview: Gillick competence and Fraser guidelines

It is vital to have an understanding of Gillick's competence and Fraser's guidelines for medicine interviews. Specifically, it is important to know when to apply each concept, how they differ, and how they are assessed.

You may be asked directly about Gillick's competence or Fraser's guidelines, or you may be asked a more general question or given a scenario in which you can apply them within your answer.

If you are dealing with a question/scenario that involves children, it is a good idea to talk about Gillick competence, and if the scenario specifically relates to sexual health, Fraser guidelines also.

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Medicine interview questions on Gillick competence and Fraser guidelines:

1. Can you explain Gillick competence and why it is important in medical practice?
2. What are the factors that healthcare professionals must consider when assessing the competence of a child under the age of 16?
3. What role does autonomy play in Gillick competence?
4. What is the difference between Gillick competence and Fraser guidelines?
5. What are the Fraser Guidelines?
6. Imagine a scenario where a child’s wishes conflict with those of their parent/guardian. How would you deal with this as a healthcare professional?
7. Can a 13 year old consent to medical intervention?
8. Describe a scenario where Gillick competence/Fraser guidelines would be applicable. How would you handle this scenario as a healthcare professional?
9. You are a GP and a 15 year-old patient presents to you seeking contraceptive advice. What do you need to consider before you proceed with the consultation?
10. (Hard) What do you do if a parents decline an intervention for a 15 year old patient that the patient wants?

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How to answer questions on Gillick's competence and Fraser guidelines:

The important things to consider when answering questions on Gillick competence and Fraser guidelines:

1. Do not confuse the two terms. Make sure you are clear on their differences before your interview.
2. Even if it is not explicitly mentioned in the question, Gillick competence can be applied to questions on children in healthcare. If Fraser guidelines don’t apply to the question, you can briefly explain why they are not relevant if you have time in your answer.
3. Make sure you know the ethical considerations of Gillick competence and Fraser guidelines, and especially how they relate to the four principles. Try to include some of these considerations in your answers.
4. If you include Gillick competence and/or Fraser guidelines in one of your answers, ensure you explain what they are. The interviewer needs to understand that you know what each term means, not just that they exist.

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Interview model question and answer – Gillick competence and Fraser guidelines:

Q: What are the factors that healthcare professionals must consider when assessing the competence of a child under the age of 16?

A: The factors to consider when assessing the competence of a child under 16 were set out in the case of Gillick. In order for a child under 16 to make their own decisions about their healthcare, they must be considered Gillick competent.

Firstly, it is important to note that Gillick competence only relates to children under the age of 16. The child then has to be deemed competent and intelligent enough to understand what is being proposed by the healthcare professional. There are many factors to consider when deciding whether a child can make a decision regarding a treatment plan/procedure.

The maturity of the child is an important factor. This can usually be grasped by talking to the child and gauging their confidence in discussing their health with a healthcare professional.

The child’s previous experiences are also an important factor to consider when judging their competence. A child who has had more experience within healthcare settings may be more enabled to make decisions about their health.

The child also needs to have enough intelligence to understand the treatment/procedure. They need to be able to weigh up the pros and cons, as well as understand the effect it will have on them.

The consideration of these factors ensures a thorough assessment of Gillick's competence. If the child wanted to discuss issues relating to contraception and sexual health, Fraser guidelines would also be used to assess whether this advice should be given.

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Conclusion

Understanding Gillick competence and Fraser guidelines is a vital part of preparation for medical school interviews. Questions on this in interviews provide a great way for you to demonstrate knowledge of the connection between law, ethics and medicine.