Doctors Who Work to Protect Children Must Keep the Interests and Needs of the Child At

GMC consultation 30/07/10 until 24/09/10

Call for evidence on doctors’ roles and responsibilities in child protection

Response of the Secular Medical Forum

Submitted online 23/09/10

Doctors who work to protect children must keep the interests and needs of the child at the heart of what they do. This means listening to children and giving them information in a way they can understand; and examining or treating children with their consent, parental consent or other legal authority. It may also involve doctors sharing information about the child and family with other agencies or when acting as a witness giving evidence to the court in order to provide services for the family or to protect a child from abuse or neglect. In these circumstances, the child and their family may have conflicting interests.

Question 1. What problems do you see in relation to consent and confidentiality when doctors work with children and their families where there are child protection concerns? If possible, please provide examples of good practice, or areas where problems commonly arise.

The GMC places 'The care of the patient' as the doctor's first concern. This applies equally to adults as to children. When considering a child's best interests, the law lords have recognised that there is usually no conflict between parental wishes and the doctor’s concern. http://www.publications.parliament.uk/pa/ld200405/ldjudgmt/jd050421/east-1.htm para. 44

Problems occur where a conflict arises between the child's best interests and the wishes of the parents. Because most parents genuinely wish the best for their children, it is generally considered to be the exception that a parent will advocate a harmful intervention. However, in our experience it is not unusual for parents to propose a harmful treatment or intervention. This is most frequently encountered when parents have strong religious or cultural beliefs. Parents with strong religious beliefs often believe that it is an infringement of their own personal rights or an attack on their religion if they are challenged. Yet a thorough informative discussion must take place between the parents and the child's doctor when parents refuse recommended treatment for their child or when they ask for a medical intervention of no therapeutic benefit.

For example, adults of the Jehovah's Witness faith may refuse a blood transfusion even where their own lives are endangered. Children's lives are put at risk when parents ask the doctor to extend this refusal of life-saving treatment to their children.

Parents may ask a doctor, often from a similar cultural or religious background, to operate on their child's genitalia to satisfy their own cultural or religious views. These vulnerable children need to be protected from unnecessary harmful medical intervention. The UN Convention on the Rights of the Child (1989) requires 'all states to take all appropriate measures with a view to abolishing traditional practices prejudicial to the health of children'.

Such requests for surgical intervention are often ill-informed, culturally expected responses by parents genuinely unaware of the serious and harmful implications of the surgery they request.

The SMF recommends that doctors educate and inform parents who make such requests. These parents are likely to be acting in what they genuinely, if misguidedly, feel is their child's best interests. The discussion should be conducted sensitively and informatively whilst bearing in mind that the final decision must be in the child's best interests whether or not the parents agree.

The GMC might consider highlighting the cultural aspect of many such requests focussing on the important educative role of the doctor. So doctors may better appreciate the important difference between challenging their patients' beliefs and educating them about harmful traditional practices. The former is unethical and inadvisable whilst the latter is an essential role for doctors.

We urge the GMC to explicitly encourage doctors to familiarise themselves with the difference between parental rights and responsibilities. Parents may bring up their children as they see fit but this right is not without limits. Where a child faces actual or imminent harm, the law recognises that society may intervene to protect the child. Parents do not have the right to cause or to risk serious avoidable harm to their children. After full discussion, where there remains a conflict between parental beliefs and medical best interests, doctors must give primacy to the medical needs of the child. This may lead to difficult conversations; there is a potential for parents to level accusations of prejudice at the doctor who challenges cherished cultural or religious practices. The alternative, to allow a child to suffer harm for fear of offending the child’s parents, is not acceptable. Doctors must be supported when they act in good faith in the child’s best interests.

Female Genital Mutilation (FGM) is unethical and illegal. It is unethical for a medical practitioner to perform non-therapeutic surgery on a non-consenting child which amounts to assault. When a girl presents to a doctor with complications from FGM, the doctor has a duty to consider both the needs of the individual child and the wider society. As with other forms of physical and sexual abuse, the appropriate authorities should be alerted to the fact that a child has been harmed and that other girls may be in imminent danger of serious harm.

The SMF notes the original 1985 female circumcision legislation and the updated 2003 FGM legislation; there have been no convictions in this time. Political and legal reasons notwithstanding, it is inconceivable that no doctor has been made aware of FGM; there is evidence that the practice continues http://www.guardian.co.uk/society/2010/jul/25/female-circumcision-children-british-law

The SMF urges the GMC to remind doctors of their duty to place the health and safety of children over and above the constraints of sensitivity to the culture or religion of the child’s parents. In some cases, the religion or culture of the doctor him or herself may blind the doctor to the harm involved in traditional practices or they may be complicit. This is particularly so when considering non-therapeutic excision of the foreskin (NTEF), otherwise known as ritual, non-therapeutic male circumcision. It is usually religious doctors or laymen who perform NTEF on children of Jews or Muslims.

The law distinguishes between non-therapeutic genital surgery on girls and boys. There is no reason for the GMC to draw such a gender distinction. All children deserve protection from non-therapeutic surgery (assault) on their genitals to satisfy cultural or religious traditional demands. No medical association in the world recommends routine non-therapeutic genital surgery. There is no evidence that NTEF confers clinical benefit and there is mounting evidence that it causes harm (Williams & Kapila 1993, British Journal of Surgery Vol. 80 1231-1236) and (Sorrells et al BJUI International Vol 99 April 2007 pp 864-869). The Dutch Medical Association, in a joint statement published in May 2010 http://www.bmj.com/content/340/bmj.c2987.extract advise that non-therapeutic ritual circumcision of boys violates their human rights. The BMA has acknowledged a similar possibility http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp

When a doctor is asked to cut the genitals of a child for no therapeutic reason, whatever the child's gender they should instead educate the parents about the harm and refuse to participate. A doctor who is asked to treat a child whose genitals have been so harmed should act as they would if they were asked to treat a child branded with a hot iron on their arm. Some people say that irreversible branding of the genitalia has more serious consequences than the irreversible branding of a child's arm. Whether or not such a comparison is useful, it is clear that, from the child's perspective, their bodies are being irreversibly altered, often painfully, for no therapeutic reason. Many adults now suffer the life-long consequences of surgery performed on them when they were powerless to refuse.

It is a testament to the power of religious deference that the non-therapeutic (i.e. clinically unnecessary) excision of a large proportion of erogenous male penile skin is permitted by default by the GMC's 'non-position.

http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs.asp#4

Earlier this year we made unsuccessful representations to the GMC to rectify this situation. http://www.secularmedicalforum.org.uk/index.php?subject=resources

Please reconsider the GMC’s complicity in forced genital cutting of infants and children for religious or cultural non-therapeutic reasons.

The SMF applauds the following GMC principles;

Doctors treating people without the capacity to make their own decisions should:

-Consider whether the patient's loss of capacity is temporary or permanent; for most children it will invariably be appropriate to defer any decisions that can wait until the child becomes an adult able to decide for themselves.

-Always take the least restrictive option; this means never performing irreversible surgery with no proven therapeutic benefit.

-Always act in the best interests of their patient; this means only providing therapeutic intervention for which there are proven benefits.

These are excellent guiding principles for all people without the capacity to make their own decisions. Whilst the Mental Capacity Act (2005) refers to adults and children over the age of 16, GMC guidance makes no distinction between adults and children without capacity. Indeed, there is every reason to use these same principles for children as well. Where conflict arises between parental expectations and clinical best interests these principles may serve as a toolkit for deciding on the most appropriate action.

The SMF is concerned that children in religious schools may miss out on important aspects of their education, in particular relating to sex and relationship education. Children in all schools will be diverse in their sexuality and need to be fully informed in order to make safe choices and to engage in safe, fulfilling sexual relationships. Other aspects of education such as contraception, STIs, menstruation, may be lacking in children from very religious families or children who are educated in some religious schools.

Doctors should be aware of their responsibilities to provide healthcare to the individual patient, should avoid assumptions based on the culture or religion of the family, and should have an increased awareness that children from religious families may not have the necessary knowledge and skills to have safe relationships. These children may lack the confidence to ask for information and should be reassured about the confidential nature of such requests.

Relationships with parents, carers and the wider family

Doctors must ensure that a child’s safety and welfare is paramount and takes priority over other considerations. But they should also ensure that the child’s family members are treated with dignity and respect, take account of the rights of family members, for example, to make decisions about their lives and lifestyle, and provide additional support or help they may need.

Please click on the 'knowledge bank' link for a definition of 'parents'

Question 2. Do you agree with this? If possible, please provide examples of circumstances where a child’s and family’s needs and rights have been met and respected in the context of child protection proceedings, or occasions where they have been in conflict and how this conflict was managed by doctors.

Members of the SMF agree that a child's safety and welfare is paramount. Parents should be allowed to make reasonable decisions about their children's upbringing. However, where a conflict arises between the parent's views and the health and welfare of the child there should be a presumption that action will be taken to ensure the child's safety.

Members of the SMF are dismayed that certain cultural practices prejudicial to the health of children are still permitted in the UK and condoned by the GMC. We recognise that the GMC does not determine the law. However, by regulating doctors' practice the GMC does have considerable influence both on individual practice and on the future development of legal safeguards to protect children. We urge the GMC to take a pro-active stance in child protection particularly where the clinically unnecessary cutting (assault) of children’s genitalia is concerned.

The SMF recommends that the GMC explicitly acknowledges that, with regard to childhood genital surgery, only such operations as are clinically indicated should be performed.

For example, non-therapeutic excision of the foreskin (NTEF) is widely practiced in the UK on children of Jewish and Muslim parents. Where concerns of child protection have been raised by doctors in this context the few GMC investigations have focussed solely on the circumstances of the procedure rather than on the underlying ethics of performing unnecessary surgical operations. Contrast this with the case of Dr Andrew Wakefield for example, who was admonished by the GMC for acting 'contrary to the clinical interests of children'. The SMF recommends that the GMC advise doctors of their obligation to use their skills for therapeutic reasons and to safeguard children.

Where a child is brought to see a doctor with a complication attributable to non-therapeutic genital surgery (assault), then it is likely that a case conference will be called for girls whilst for boys there is literally no protection, even where the procedure was performed by a lay person. We urge the GMC to remedy this situation by issuing unequivocal guidance against any intervention on children that is not in the child's best clinical interests.

Doctors working in partnership

Doctors are expected to work as part of a team alongside other health professionals when they provide treatment and care to a child or young person. Doctors are expected to cooperate with other agencies, such as services for children and young people and the police, where abuse or neglect of a child or young person is suspected or known. Doctors may also be asked to work with colleagues when giving evidence to a court, for example when the court asks experts for all the parties on a case to advise the court on issues on which they agree or disagree.

Question 3. What are your views or experiences about how well doctors work with other doctors, professionals and agencies, when there is the possibility of harm to a child?

This response deals only with the particular concerns of the Secular Medical Forum, advocating equality of care for all patients irrespective of their own or their doctor's own personal beliefs.

Members of the SMF have noted the reluctance of some professionals to challenge harm perpetrated on children when it has been religiously motivated. Examples of this include reluctance to challenge a family's belief that their child has been 'possessed' and is a witch, or reluctance to address FGM or Non-therapeutic Excision of the Foreskin (NTEF) in males.