In any discussion regarding the medical care to be provided to a child, it is essential to provide complete and clear information that is context and, where necessary, age appropriate. While adult decision making is seemingly free of restriction, for children it is still acknowledged that "The graver the consequences of the decision, the commensurately greater the level of competence is required to take the decision."15 In young children and children who lack capacity then those with parental responsibility are charged with the responsibility to make informed decisions on the child's behalf. For the vast majority of interactions this will accord with the prevailing view on choices that sit within those that might be considered in the best interests of the child concerned, which will be both family and decision specific. However, on occasions there will be parental dispute or the decision will seem to be sufficiently anomalous that it might be contrary to the child's best interests. Meanwhile, the competent minor is provided the right of increasing self-determination and can, with greater maturity, weigh up (more) complex medical decisions for his/her own care. Many potential decisions will be acceded to, viewed as a reasonable approach for an individual in that particular situation. While the child's parents are likely to be intimately involved in supporting their child in reaching a decision, or in providing consent on his/her behalf, this is no longer essential even though parental input is encouraged. Ultimately, a competent minor can provide affirmative, informed consent. Irrespective of whether a competent child's decision or parental expression on behalf of their child who lacks capacity, if this declines medical intervention considered in their best interests, where possible, and time allowing, this might be resolved through further discussion, greater explanation, wider professional (ie, social services, other specialties or therapists) or family involvement (subject to consent) and time. In the urgent situation or should an impasse be reached, then an application to the Court may be necessary. The child's welfare, or best interests, will prevail; although this may require reviewing from numerous perspectives, particularly for the younger, incompetent child, where the issues may be less pressing, non-essential or urgent and life-preserving. For the competent minor, the issues more likely relate to urgent life-preserving interventions, and here the Courts will typically authorise treatment to ensure the competent minor reaches the age of majority, even though their reasons will be carefully reviewed, save for distressing treatment that has a reduced likelihood of being successful. Where requests for medical treatments not deemed to be in the child's best interests are received, the doctor is not obliged to provide the intervention sought;16 although again this requires exploration with the patient and/or family and might indicate an underlying safeguarding concern. The initial principles for approaching these situations are similar to treatment refusal listed above. Decisions of this magnitude are rare and may adversely affect the therapeutic relationship, so are not taken lightly and require expert legal input along the way. Advice is available from experienced colleagues, your employing or contracting body's legal department and/or your MDO. As part of this, it is essential to ensure that all decisions and discussions are fully documented and justify the direction taken, should this be challenged in future. Ultimately, the child's welfare is paramount, the first and final consideration of every parent, doctor and (where necessary) the Court.
