Consent, parental responsibility and mature-minor frameworks — formative SAQs

SAQ 1 — Mature-minor capacity and confidential care (10 marks)

A 15-year-old presents alone requesting a long-acting contraceptive implant. She is fearful of her parents finding out, speaks English well, and understands she is asking for a reversible method. [4] [12]

Questions

1. Name the four Appelbaum capacity domains and show how you would assess each at the bedside for this decision. (4 marks) [3]
2. Outline how you would approach confidentiality and the involvement of a trusted adult. (3 marks) [4]
3. State the principle that governs the operational threshold for adolescent contraception and explain why you would not quote a fixed age. (3 marks) [1]

Model answer

Capacity domains (4). Understand — ask her to restate, in her own words, what the implant is and how it works, using teach-back. Appreciate — confirm she grasps how it applies to her own life and relationships, not in the abstract. Reason — explore whether she can weigh the benefits, risks and alternatives and give reasons for her choice. Choose — confirm she can communicate a stable, voluntary preference and is not being coerced. [3]

Confidentiality and trusted adult (3). Explain honestly that confidentiality is upheld within its legal limits, and that safeguarding concerns would override it. Explore whether a trusted adult could be involved without forcing disclosure, and offer to support that conversation rather than dictate it. Document what was discussed about confidentiality and its limits. [4] [12]

Operational threshold (3). The governing principle is functional, decision-specific capacity rather than a fixed age: a capable minor can consent to the specific decision. The operational threshold is set by local statute, case law and hospital policy, so you direct the examiner to "check local statute and policy" rather than inventing an age or section number. [1]

SAQ 2 — Emergency necessity, refusal and the harm principle (10 marks)

A non-capable 4-year-old with suspected sepsis needs intravenous antibiotics and fluids. The parents refuse, citing mistrust of hospitals. The child is tiring and lactate is rising. [8] [1]

Questions

1. State the emergency-treatment principle and what you must document. (3 marks) [1]
2. Explain how the harm principle applies to overriding parental refusal for a non-capable child. (4 marks) [8]
3. Contrast this with a capable adolescent's refusal of life-saving treatment, and name the escalation pathway. (3 marks) [10]

Model answer

Emergency principle (3). When delay risks death or serious harm and a decision-maker refuses or is absent, treat immediately what prevents that harm under emergency necessity. Document the specific threat you were preventing, the necessity basis, and plan to revisit full consent once the child is stable. [1]

Harm principle (4). Diekema framed the harm principle as the threshold for state intervention over parental refusal: where refusal risks serious, foreseeable and imminent harm, the state may override the parent. In rising sepsis this threshold is met, so you treat and escalate to senior clinician, ethics and usually the courts — not a unilateral bedside override in isolation. [8]

Capable adolescent contrast (3). A capable adolescent's informed refusal of life-saving care is a genuine legal-ethical crisis, not an automatic override. Courts internationally have moved toward overriding refusal of life-saving treatment in minors under defined conditions, but the pathway is senior clinician, ethics consultation and legal or court input — never a solo decision. [10]