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Chapter: Paediatrics: Paediatrics, ethics, and the law

Paediatrics: Assent and consent

In the USA, the term ‘assent’ in a child is used to distinguish valid ‘consent’ from a competent adult.

Assent and consent


In the USA, the term ‘assent’ in a child is used to distinguish valid ‘consent’ from a competent adult. The American Academy of Pediatrics suggests that assent should include at least the following elements:


·  Helping the patient achieve a developmentally appropriate awareness: of the nature of his or her condition.

·  Telling the patient what to expect: with tests and treatment.

·  Making a clinical assessment of the patient’s understanding of the situation: the factors influencing how he or she is responding (including whether there is inappropriate pressure to accept testing or therapy).

·  Soliciting an expression of the patient’s willingness to accept the proposed care: do not solicit a patient’s view without intending to weigh it seriously. Where the patient will have to receive medical care in spite of his/her objection, tell the patient that fact. Do not deceive them.


The American Academy of Pediatrics suggests that clinicians seek the assent of the school-age patient as well as informed permission of the parent for procedures such as:

·  Venepuncture for diagnostic study in a 9-yr-old;


·  Orthopaedic surgery device for scoliosis in an 11-yr-old.


With regard to consent, the clinician must present information in a man-ner suited to the child’s developmental level. Parents should be able to assist, but in some cases they may be too close to the situation to assess the child’s state accurately. Other professionals can provide important insight into a particular child’s developmental level and comprehension of the information presented. In the process of consent, the child’s situation influences each of these elements:

·  Nature and the purpose of the therapy.


·  Risk and consequences of therapy, and of not having therapy.


·  Benefits and the probability that therapy will be successful.


·  Feasible alternatives.




In the UK, consent must be sufficiently informed and freely given by the designated person who is competent to do so..

·  The adolescent if aged >16yrs.


·  The adolescent if aged <16yrs and judged to be competent.


·  Parents.


·  Individual or local authority with parental responsibility.


·  A court.




Defining whether an adolescent demonstrates competence can be difficult and may depend on the nature of the procedure, as well as the child. The adolescent must possess qualities associated with self-determination and self-identity, appropriate cognitive abilities, and the ability to rationalize and reason hypothetically. Understanding, intelligence, and experience are also important qualities that may determine competence.

Criteria for establishing competence


The patient must:

·Demonstrate an understanding of the nature, purpose, and necessity of the proposed therapy.


·Demonstrate and understanding of the benefits, risks, and potential consequences of not having the treatment.


·Understand that this information applies to him/her.


·Retain and use that information to make decision.


·Ensure their decision is made without being pressurized.


Assessing competence is the legal responsibility of the patient’s doctor or other designated health care professional. A patient’s refusal to co-operate with competence assessment should not be regarded as demonstrating incompetence. In England, Wales, and Northern Ireland adolescents aged 16–18yrs can consent to treatment, but cannot refuse treatment that is otherwise intended to prevent their serious harm or death. Adolescents aged less than 16yrs may legally consent to treatment if they fulfill the criteria for competence. In Scotland, all children and adolescents may con-sent to treatment irrespective of age, so long as they are deemed com-petent to do so.


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