Consider an ordinary referral for a hyperactive child, who is assessed, diagnosed, and treated. We begin by meeting our legal duty to manage the referral to ensure it is treated optimally.
7 We seek consent, aware that assessment or treatment without consent normally constitutes the legal offence of battery.
7 Usually we seek consent from the parents, but try to take the child's views and wishes into account. Despite concerns about whether this offers children, particularly teenagers, sufficient autonomy, the overwhelming weight of law and guidance is on our side.
8 We undertake a thorough assessment and treat on its basis, ensuring both assessment and treatment consistent with current professional guidelines,
9 meeting the legal requirement that our practice should be both reasonable and agreed with our peers.
10 This process clearly involves respect for autonomy in obtaining appropriate consent, beneficence, and non‐maleficence in providing appropriate care. Justice is also involved, though less obviously: for example, we consider it just (fair) to be expected to manage the assessment and medical treatment of these cases well, while the legal framework and guidance just outlined tells us what “well” means. Our model tells us that, if we approach ordinary cases of hyperactivity in an ordinary way, we are acting both ethically and legally. There is more to this than reassurance. Despite the controversy surrounding it, the diagnosis of hyperactivity is at least as well established as other medical diagnoses.
11,12 So, our model permits us to use the diagnosis despite doubt, while philosophical or theoretical objections are not sufficient grounds to refuse to make the diagnosis—any objections must be specified in terms of the model. The model similarly makes clear that we should not be swayed by prejudice in treatment: being “against medication” must be justifiable in terms of the individual patient, against the standards set by the model. In both cases, the alternative is to risk ethical criticism or even legal sanction. Ethical practice is not political correctness.
Given the safety of the treatments available for hyperactivity,
13 and the significant disability the condition imposes,
14 beneficence and non‐maleficence rarely conflict. Respect for autonomy presents few challenges at initial assessment, as the children are usually so young that one may place the overwhelming responsibility for consent on the parents who have brought the child and still respect the child's autonomy. As the treatment is over several years, the model suggests that the child's appreciation of the treatment should be reviewed as time passes, to ensure that practitioners appreciate how the balance of autonomy is shifting, and can respond to it as necessary. “Gillick competence”—that is, to understand the treatment and its benefits sufficiently to give informed consent, which a child must possess in order to give consent independent without parents, is based on an assessment of the child's competencies, not age.
15 Though a child's wishes may be overruled until 18, assessment of autonomy is essential to ensure that sufficient weight is given to the child's views, as in the case of an older child they may not be overset lightly.
16,17 Only those with parental responsibility can give consent for more than immediate or emergency treatment, though only one parent is needed to consent.
18 People who
cannot give full consent include teachers at boarding schools, foster‐carers, unmarried fathers, or stepfathers who have not been granted parental rights by a court, and social workers unless the child is under a care order—being “accommodated” or under a supervision order will not do. So, practitioners must be careful that the adult with the child is actually able to give consent, if the child (as is usually the case in hyperactivity) is not “Gillick” competent.
Commonly, hyperactivity presents practitioners with ethical conflicts between beneficence/non‐maleficence and justice. Teachers may tell practitioners, before diagnosis, that the child will not be allowed back to school unless medicated, or a diagnosis is required before special educational provision is made available. Hyperactive impulsivity can lead to demands for retribution from its victims, either informally or through the courts. Each reader can no doubt think of their own examples. In all of these situations the model directs us to first consider the needs of the child, as the object of our actions. We must then balance the conflicting principles, specified by our professional knowledge and the legal framework, to ensure the best possible outcome for the child. For example, in the case of the school requiring medication before admission, the model would indicate contact with the school to educate them about medication's uses and limitations, rather than either flat opposition (which would be in breach of educational and medical guidance about joint working) or uncritical agreement (which neglects making proper medical judgement of the needs of the child). Having thus specified and balanced, we hope that a resolution will arise through the dialectic with the school.
