The issue of the age of consent for medical treatment has been in the media a lot recently, with reports about an 11-year-old Ontario boy who chose to forgo potentially life-saving chemotherapy. The story raised a great deal of discussion in Canada, particularly because the survival of the child is in no way guaranteed, and because the consequences of chemotherapy can be very significant. An adult who chose not to pursue treatment would, almost certainly, have had his wishes respected. Yet the courts decided that this not-quite-adolescent and his parents have no choice; therapy will proceed.

• Related: Boy forced to get chemo treatments returned to parents

Pediatricians run into issues of consent and related privacy concerns all the time. At the crux of our decision-making processes are a couple of principles.

First, the child should be approached with respect; that means respect for his needs, his fears, his intellect, and his rights. Even in those cases where we have to disagree with a child, we need to listen, inform and, critically, accommodate him and his parents as much as possible.

Secondly, we have to care for the child. One of the profound differences in the care of children compared to adults is that paternalism (and maternalism) isn't just common, it's appropriate.

We aren't the parents to these children, but we are parent-like. We owe our allegiances first to the child, and very distinctly to the parents second. Parents sometimes feel that they have the final say in the care of their child, and to a large extent this is true. But not always. In theory, when I see a three-year-old, I am her doctor, not mom's, not dad's. When the crunch comes and the parents refuse treatment or investigations that I feel might be life- or-limb-saving, their wishes may very well fall by the wayside.

Does that sound scary? It should. As parents, we don't like the implication that we are not competent to care for our children. A health-care and legal system that ignores our wishes can seem to declare us unfit to make critical decisions, and this rocks parents to the core. Fundamental to these decisions is the child's (and parent's) ability to understand the consequences of their actions.

For example, let's say that we have a two-year-old child who has pneumonia and is vomiting. If she can't keep oral antibiotics down, the appropriate response is to give an equivalent medication by IV. The parents understand the issue and agree. The two-year-old, emphatically, does not.

The response to this circumstance is obvious; the child gets the IV, even if that means restraining her for the few minutes it takes to get the poke. I doubt that anyone would disagree. The patient, in this case, is too young to have consent, and the parents are in agreement.

But suppose we tweak this case a little. Say the parent has a profound needle phobia, and won't agree to placement of the IV. Now both child and parent refuse consent. What do we do? Well, that depends on the severity of the pneumonia. If this were a typical, rather low-risk circumstance, most of us would explore other options. We would admit the child to hospital, and let the (expert) nurses on the wards try to get oral medication into the child. If this worked, we could avoid the consent issue altogether. If it didn't, the child's parent would have the opportunity to see our legitimate attempts fail, see their child continue to be ill, and likely would eventually agree with IV placement. By clearly trying to accommodate the parent's wishes, we build bridges. And we rely, almost always with good reason, on the ability of parents to see what is best for their children and to make decisions that are hard for them, once they are given a little support.

What if, though, the child is in dire straits, and we don't have the luxury of time? Or if deterioration occurs and no agreement can be reached? In these cases, the physicians have absolutely no choice; by law they are required to report the circumstances to children's services, and the process is to seek a court order. This is intended to guarantee that an arm's length respected third party (the judge) can make a ruling so that simple personality conflict or heavy-handedness on the part of physicians can't limit parental rights. In practice, if the evidence is clearly presented, court orders are almost always granted.

Privacy rights

Consent is complex, and it extends beyond treatment to children's privacy rights. For example, suppose that a 15-year-old girl asks her family physician for birth control. She does not want her parents to know about this. Can (should) the doctor prescribe the medication?

Almost certainly, the answer is yes, as long as the physician can be convinced that the child understands the risks and benefits of the pill. Other issues, such as the safety of her current sexual relationship and the impact that sexuality is having on her, as well as other issues specific to adolescents, should also be explored. But mom very likely wouldn't be told about the prescription. Nor, in my view, should she.

Now, how would that scenario change if the girl was 14? Or 12? Clearly as the child gets younger, the anxiety in the physician would become greater. Will the provision of birth control help protect her? Or simply make her more vulnerable? According to legislation enacted in May, children 12 to 13 can consent to "non-exploitive" sexual activity with partners no more than two years older than themselves (children 14 and 15 can consent to sex with partners no more than five years older than themselves). So as long as the child is 12 or older, there is at least theoretical support for giving her the pill, with the onus on the physician to somehow be satisfied that the child is safe. In practice, most physicians would be very leery, and a strong attempt to convince the child to talk to her parents about her relationship would probably be made.

Similar rules apply to other privacy issues. It is common to see adolescents in the emergency department for psychosocial concerns; often when talking to these kids alone they disclose some aspect of their lives to me that they don't want told to their parents. They are being bullied, but aren't ready to talk about it yet. They smoke marijuana on weekends. They engage in risky sexual activity. If these kids can grasp the consequences of their actions (and the test for this here, basically, is that they are developmentally normal), then all of this is privileged information. I can't (and don't want to) share it with their parents without their consent.

If mom thinks that her adolescent son has fallen off the wagon and is back on drugs, or that her daughter might be pregnant, can I take a urine sample and covertly do the diagnostic test? Nope. Not without the consent of the child. Can I test the child for pregnancy and not tell her parent about the positive result? In fact, I am required to keep the child's confidence, although in that case I would, again, be trying hard to convince my patient otherwise.

Now suppose that my 14-year-old patient tells me she is being abused by an older person (as defined above), or is suicidal, or has such anger that she is a physical threat to someone else. Whether she wants me to disclose this to others or not, legislation gives me no legal option; this story gets reported to the appropriate authorities, and eventually almost certainly the parents will be informed.

It should be clear by now that the thorniest consent issues are (fortunately) out of the hands of the physician; there are legal restrictions around what I must disclose, and rules of conduct that specify what I can't. The wiggle room comes in that critical assessment of whether the child is "capable" of consent. The older you get as a clinician, the more you ask for help; in the most difficult cases, a team of psychologists, psychiatrists, social workers as well as the physician ultimately makes the decision to disclose or not.

The simplistic approach to these cases simply doesn't work. The idea that permitting consent is somehow "pandering" to a child is fundamentally flawed. Children have the right to be informed, and to consent at the level at which they are capable. I ask every toddler if I can please take off their shirt in order to examine them. Some of these kids have incredible body shyness, while others will happily run around the department naked. The consent I receive from these little ones is important, and respected. I can work around their issues. This isn't pandering. This is just being polite.

Similarly, the idea that physicians are arrogantly running roughshod over children's rights is foolish and ill-informed. The decisions around these cases are incredibly stressful, and no one I know takes them lightly. In fact, the guidelines and legal requirements intrinsic to our profession make it very difficult to do otherwise. Doctors don't "take kids away from parents"; rather, they ask the courts to tell them what to do in very difficult circumstances, and abide by those decisions.

The 11-year-old boy in Ontario is someone we all ache for. And we ache for his parents too; who among us can imagine the stress after years of difficult therapy and the profound disappointment and fear associated with the return of his disease?

In a very important way, though, the story also speaks to the processes involved in these terribly trying cases. Each individual had a voice here; the parents and the physicians spoke on behalf of the child, each as advocates for him. The boy's wishes were heard, given the highest consideration, and his ability to understand the circumstances assessed. The decision made was rational, whether you agree with it or not. In many respects, it is a good model for how the system should work.

Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is available at www.thevirtualpediatrician.com.

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