Consent, assent and parental responsibility

Separate three concepts. Consent gives legal authority for an intervention. Capacity or competence describes the decision-maker's ability for this decision now. Parental responsibility identifies which adults can make decisions for a child who cannot. Assent is the child's affirmative involvement even when another person provides legal consent. Good paediatric practice addresses all four rather than obtaining a signature from whichever adult arrived.

For any valid decision, provide understandable information about diagnosis or uncertainty, proposed intervention, expected benefit, material risks, reasonable alternatives, no treatment and practical consequences. Check understanding and voluntariness and allow questions. Adapt language, interpreter, visual support and time. Consent is a process and can be withdrawn. A form records part of it but does not make an uninformed or coerced decision valid.

At 16 and 17, a young person is presumed to have capacity to consent to treatment. Assess capacity when there is reason for concern using the decision-specific abilities to understand, retain, use or weigh and communicate. The Mental Capacity Act framework applies from age 16 in England and Wales, while paediatric and family law still matters. Support the young person before concluding incapacity; fear, learning disability, intoxication, pain and acute illness may be temporary barriers.

Below 16, assess Gillick competence. The child must understand the nature, purpose, likely effects, important risks, alternatives and consequences of accepting or refusing sufficiently to make this particular choice. There is no single age, questionnaire or diagnosis that proves competence. Maturity, experience and complexity matter. Document the information explored and the child's reasoning rather than writing only ‘Gillick competent’.

A competent child can consent to treatment, including confidential advice in appropriate circumstances. Encourage involvement of parents or another trusted adult when this benefits the child, but do not disclose automatically. GMC guidance requires respecting confidentiality unless the child agrees, law requires disclosure or sharing is justified to protect the child or others from risk of death or serious harm. Tell the young person what will be shared when safe.

Assent remains essential when legal consent comes from an adult. Tell a toddler what the stethoscope does, let a school child choose a position and explain a procedure to a young person with learning disability using their communication system. Distinguish fear from refusal and use analgesia, preparation and play. Persistent dissent about non-urgent intervention should prompt pause and review. Necessary urgent care may require proportionate holding under an approved policy, not punitive restraint.

Parental responsibility varies by law and circumstances. A birth mother has it; fathers and second parents may acquire it through marriage or civil partnership, birth registration, agreement or court order, and adoptive parents and appointed guardians can hold it. Foster carers, grandparents, step-parents and accompanying relatives do not necessarily have it. Check the clinical record and ask the basis of authority rather than demanding legal documents for every routine interaction.

One holder of parental responsibility can usually consent, but clinicians should involve those important to the child where practical and consistent with confidentiality and safety. If holders disagree about significant non-urgent care, do not choose the most convenient answer. Clarify the child's welfare, seek senior and legal advice and consider court determination. Routine care should not be paralysed by minor disagreement, while irreversible or highly contested interventions deserve formal resolution.

A parental decision must promote the child's welfare. Refusal of beneficial low-stakes care may be negotiated through explanation and alternatives. When refusal exposes the child to death or serious irreversible harm, involve senior paediatrics, safeguarding and the organisation's legal team urgently. A court can determine best interests when time permits. In a true emergency, give immediately necessary treatment and seek authority for continuing treatment afterwards.

Refusal by a competent child or 16–17-year-old is more complex than consent. The courts can in some circumstances authorise treatment despite refusal, particularly to prevent grave harm, but a clinician should not assume that parental agreement automatically settles the issue. Explore reasons, treat pain or mental illness, offer advocacy and a second opinion and obtain urgent legal advice for high-consequence conflict. Preserve dignity and trust while maintaining safety.

When a child lacks competence, the decision focuses on best interests: clinical benefit and burden, wishes and feelings, beliefs and values, relationships, less restrictive options and the views of those caring for them. Disability alone never means treatment is futile or capacity absent. For a 16–17-year-old lacking capacity, follow the Mental Capacity Act and relevant family-law advice. An advance plan from a specialist team should be reviewed, not accepted uncritically when circumstances have changed.

Documentation should make the decision reproducible. Record identity and role of everyone present, parental-responsibility basis, interpreter, information and materials, material risks discussed, questions, child and parent views, competence or capacity reasoning and final plan. In remote consent, confirm identity and authority. For recurring treatment, define what period and changes require renewed discussion. Handover any refusal, restriction or confidentiality boundary clearly and securely.