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The rights of a child
Current Paediatrics (2001) 11, 28d32 ^ 2001 Harcourt Publishers Ltd doi:10.1054/cupe.2001.0138, available online at http://www.idealibrary.com on 0146
The rights of a child T. Waterston and E. Curtis Consultant Paediatricians, Community Paediatrics Department, Newcastle General Hospital, Arthur’s Hill Clinic, Douglas Terrace, Newcastle upon Tyne NE4 OBE, UK
INTRODUCTION In this paper we hope to illustrate the importance of children’s rights in paediatric practice, to explore the rationale of the UN Convention on the Rights of the Child and its application in UK, and to examine how we can make our practice more child centred, whilst not neglecting the role of parents.
ISSUES FOR PAEDIATRICIANS: WHY IS IT IMPORTANT FOR US? Respect for children and young people’s civil and political rights is integral to the practice of many paediatricians but there is scope for improvement The underlying principle of the 54 articles in the UN Convention is expressed in article 3 stating ‘In all actions concerning children2the best interests of the child shall be a primary consideration’. Important issues include confidentiality, consent, the manner of the consultation, communication and the rights of children in minority groups. Here, we present examples of some of these and look at the principles of management.
CONFIDENTIALITY The right to confidentiality should be explicit and advertized openly in the clinical setting (Article 16). Confidentiality should be breached only if there is a risk to the child concerned, or to another, and this should be made clear to the child from the start. If it is considered necessary to breach confidentiality, the reasons for this should be discussed with the child and he/she should be supported through the ensuing process.
Case study Jane, a 15-year-old, asks you, her GP, to arrange a termination as she is pregnant as a result of
Correspondence to TW.
unprotected sex with her boyfriend. Recently, you have seen her infrequently but knew her as a child and see her mother quite often for anxiety. She asks you not to tell her parents. Jane’s mother has an appointment to see you tomorrow and you know that she will discuss Jane with you as she has been truanting from school recently. This consultation will require time. The pregnancy needs to be confirmed and the father’s views considered; perhaps both partners could be seen together if Jane felt that would be helpful. The GP needs to discuss with Jane the possible options and the consequences of her decisions to have a termination and not to involve her parents. If, following this discussion, Jane is sure that this is what she wants then a reasonable approach is to support her in this.
CONSENT With regard to the issue of consent, Alderson1 has shown that children younger than 10 years old, prepared in an age-appropriate manner were able to give informed consent to orthopaedic surgery. Consent, as defined by the Department of Health and the Welsh Office (1990), needs to be fully informed and freely given, using language which the child can understand. The child must feel autonomous, free to make his or her own choice and should have a simple explanation of consequences which might be difficult to foresee. Article 5 recognizes that parental rights must be exercised in line with the ‘evolving capacities of the child’. The legal issues with regard to consent by children in the UK are not entirely clear. The Family Law Reform Act 1969, the Age of Majority Act (Northern Ireland) 1969 and the Age of Legal Capacity Act (Scotland) 1991 gave young people aged 16 years and over an independent right to consent to surgical or medical treatment. Consent in younger children is governed by the Gillick judgement which established that children under 16 years can give legally effective consent to surgical or medical treatment, independent of their parents’ wishes, provided they have sufficient understanding of their condition and what is proposed.
THE RIGHT OF THE CHILD The practitioner must learn to assess and accept children’s competence. Refusal of treatment is somewhat different and case law has established that if a young person under 18 years chooses to refuse treatment, their wishes may legally be overruled by their parent or carer.
Case study Mark, a 13-year-old, is due for the measles and rubella (MR) catch up immunization which is being given in school. He has not brought a consent form from his parents and the year tutor thinks they may be opposed. However, he had seen the video which was shown about measles and rubella and thinks he should be immunized. The school nurse asks you as the school paediatrician if this is alright as she does not expect to be doing another school session in the near future, and an epidemic of measles has been predicted. Legally it is acceptable to go ahead with the immunization under these circumstances, but may not be wise as it could cause a rift with the parents and the injection is not strictly urgent. The anticipatory approach would be to send out a letter to parents in advance saying that children’s consent may be used and recommending that children discuss this with their parents.
MENTAL HEALTH For child health practitioners working in the area of mental health there are a number of important issues. A mental health consultation is rarely initiated by children making it difficult to consent to the process or to truly participate in it. They are the subject of the conversation and may be embarrassed by open discussion of their shortcomings. In residential or day hospital settings, restraint is sometimes used if a child is disturbed and at risk of causing harm to themselves or others. The manner of this may violate article 19 (‘State parties shall 2protect the child from all forms of physical or mental violence2’). It is helpful to acknowledge the child’s experience of being the subject of the consultation, to acknowledge their relative absence of a voice, to give the child a clear explanation of the status of their involvement and to use appropriate, simple, jargon-free language.
PARTICIPATION At present most staff in the health services have had little discussion of children’s rights issues in their training. Communication with children and young adults is a skill which is only natural to a few people. Managers should arrange regular training sessions for staff groups on children’s rights and communication with children, if
29 possible using the input and experience of young people themselves. Article 12 states the right of children to express views on matters of concern to them and there is need for improvement in how we consult with and involve children and young people in the development of the services provided for them.
Case study You are the school doctor for a high school which has many problems of risk-taking in adolescents, including smoking, alcohol and drug use. Recently there have been several pregnancies in the school. You are asked for your view on how the health services can contribute to prevention and you feel that the view of the pupils should be sought. How would you go about doing this? There are a number of ways in which the views of young people can be sought. In this case, the doctor could either go to the School Council if one exists, or carry out focus groups with different age groups of pupils.
Case study The children’s department of the hospital where you are the clinical director is planning to develop a new facility, for adolescent inpatients and outpatients with chronic health problems. This will be situated in an area adjacent to the outpatient department. The department would like the adolescents who use the hospital to be involved in planning the facility. How would this be brought about? Here, it is important to approach the users of the service. Every young person attending the outpatient department over a specified period could be informed that a consultation was taking place and invited to join a group with a member of staff as facilitator. The ideas presented could be displayed in the outpatient department and comments sought from all users. Other areas which we may not immediately consider include the right of children to non-discrimination (article 2); and the importance of racial awareness training for health workers. Article 23 affirms the right of disabled children to fullest possible social integration. The Children Act Report 1993 noted a wide disparity in the levels of skill and expertise of staff working with disabled children and that it was not a habit to request or record the views of disabled children about decisions affecting their daily lives and futures.
BACKGROUND TO THE UN CONVENTION AND DEFINITION OF CHILDREN’S RIGHTS The idea that children have separate rights is a relatively recent and still somewhat alien concept to many people.
30 The concept of ‘ownership’ of their children comes naturally to parents in most parts of the world. Children are not always seen as a priority group in society and their education, health, growth and mental well-being may suffer as a result of the economic priorities of adults. Children are exploited all round the world, both child labour and prostitution are common and in many countries children are inducted into the army and fight in wars. Children’s rights are not only about consent to operations and confidentiality, important as these are to the practising paediatrician, but there are basic principles to be upheld and global injustices which violate these. The concept of children’s rights was first raised by Eglantine Jebb, the founder of Save the Children in England in the early part of the 20th century. This was a time when child labour and child exploitation were common and child illness was a killer. Children were not regarded as separate persons but as possessions of their parents. Over time, the perception of children has changed greatly to the extent that, in many countries, they now have a highly protected childhood, indeed they are not regarded as adults until they are over the age of 18. Children’s rights were first codified and defined in the UN Convention on the Rights of the Child which is described below. The UN Convention applies to the actions of States. The Convention places children’s rights in a universalist and international context. It behoves paediatricians, in their role as advocates for children, to understand its principles and seek assurance from their governments that it is being implemented. They also need to look at their own work and relationships in the context of the convention. The UN Convention itself had a long gestation before being finally adopted by the United Nations in 1989. It was ratified by the UK government in 1991 soon after the Children Act came into force. The convention has been ratified by all countries in the world bar two, namely Somalia and the USA. The main categories of rights are the rights to survival and development, to free expression of views and freedom of expression, to access to information and to privacy, to protection from all kinds of harm, to good health and education, and protection from exploitation (Box 1). As in the England and Wales Children Act the best interests of the child are recognized as being fundamental in all legislation. However, the Convention is much more wide-ranging than the Children Act. Since October 2000, as a result of the UK Human Rights Act, all legislation in UK must be read and given effect in a way which is compatible with the European Convention on Human Rights (ECHR). This will generally strengthen children’s rights as UNCRC has always been taken into account in decisions by the ECHR. All caselaw decided in Europe will become relevant to the UK, hence for example decisions taken on the placement of children
CURRENT PAEDIATRICS
Box 1 UN Convention on the Rights of the Child E Best interests of the child to be a primary consideration in legislation E Rights to survival and development E Rights to express their views and freedom of expression E Access to information of benefit and protection from injurious information E Protection from violence, abuse and neglect E Right to the highest attainable standard of health E Right to an adequate standard of living E Protection from economic exploitation
in Sweden would appertain to UK. The two relevant articles of ECHR in relation to child health are Article 3 (No one shall be subjected to torture or inhumane or degrading treatment or punishment) which may affect government decisions on legislation concerning corporal punishment, and Article 8 (Everyone has the right to respect for his private and family life, his home and his correspondence) which may affect decisions in relation to social services placement of children (e.g. if a child is not placed for adoption and is on a Care Order then it has to be assumed that the ultimate aim of the plan is for reunification). Hence, the application of the Convention in the UK will require positive action by education departments, social services, juvenile justice, the Home Office and the Treasury as well as by the health departments. Its principles also need to be understood by a wide range of professionals working with children including parents. The issues which still cause difficulty in health care have been outlined previously.
CHILDREN’S RIGHTS: GLOBAL ISSUES The convention has equal relevance in all countries of the world. However, problems such as malnutrition, war, child labour and prostitution, female genital mutilation, homelessness and refugee status are experienced to a much greater extent by children living in the developing world. UNICEF’s annual report, the State of the World’s Children,2 gives graphic illustration of these problems which are in many cases worsening as the gap between rich and poor countries increases. Poverty, in the developing world, caused by the North’s historic economic exploitation of the South, make it impossible for many developing countries to even start applying the Convention. Transnational corporations are often at fault in exploiting child labour and paediatricians as
THE RIGHT OF THE CHILD advocates for child health have a role in pointing out the ill effects of such malpractice.
STATUS OF CHILDREN’S RIGHTS IN THE UK: WE COULD DO BETTER Each ratifying country is expected to report on its progress after 2 years and then at 5 yearly intervals. The UK reported in January 1995 and the UN committee made observations on this report which have been published.3 The committee congratulated the government on the Children Act, on initiatives to reduce Sudden Infant Death and combat bullying in schools, on the Working Together document on child abuse, and on the planned extension of the pre-school education provision. It expressed concern about a number of areas of activity which included: E
E
E
E
E
E
The lack of an independent mechanism to monitor the implementation of the Rights of the Child The absence of mechanisms to prevent the illtreatment of children in Northern Ireland under the emergency legislation The principle of ‘Best interests of the child’ is not reflected in health, education and social security legislation The lack of attention given to the rights of the child to express an opinion, for example, in school exclusion or when parents decide to withdraw their children from the sex education programme Private schools still being permitted to administer corporal punishment The increasing numbers of children living in poverty.
The Children’s Rights Office (CRO), a nongovernmental organization coordinating efforts to promote children’s rights in the UK, urged the government to respond to the recommendations made by the UN committee in advance of the next report due in 1999. In that report, there were improvements noted in the government’s practice but there were still felt to be notable deficiencies. The CRO considers that the most important action would be the appointment of an independent children’s commissioner, or ombudsman, together with a clear government strategy for children and, as exists in other European countries, the appointment of a minister for children. Wales has recently appointed an independent children’s commissioner but this has not yet happened in England. Paediatricians and others have recently highlighted the lack of a voice for children in government in the UK.4 In society at large, such appointments would increase national publicity with regard to children’s interests; would allow children an independent appeal mechanism; and would encourage greater discussion on the requirements of the convention. The expression of
31 children’s views is almost always reasonable and young people make it clear that they would like to work with adults.
ISSUES FOR PURCHASERS AND PROVIDERS Implementation of the UN convention in the health service will require action by purchasers and providers as well as by the Department of Health. The BACCH practitioners’ guide ‘Child Health Rights’5 contains many useful suggestions and should be available to all managers of child health services and to those responsible for commissioning services for children. The main areas in which managers could bring about change are in policy, in training, in the provision of information and in consultation. Policy guidelines should be available for all staff (Box 2). The issues of children’s rights need to be understood and implemented equally by doctors, ward nurses, auxiliaries, receptionists, practice nurses, school nurses, porters, laboratory staff and therapists and guidance should be available, written into contracts and monitored. There should be a review of the written and visual information available for children and their parents. Information should be available for parents and children about the hospital or health centre’s policy with regard to children’s rights so that they know what to expect in relation to the collecting of consent. Information should be available for children, as well as parents, on the commonly occurring conditions, and this information should be at an age-appropriate reading level. If new material is to be developed, young people could assist in preparing and reviewing it. Material should also be available for children and young people whose first language is not English.
Box 2 Guidelines for children’s services Written policy should be made available to all staff who deal with children including guidelines on: E E
E E E
E
Respect for children’s autonomy Availability of age appropriate information on illnesses, conditions, treatments and procedures Children’s consent and refusal of treatment Confidentiality Availability of separate consultation for young people if they wish it Involvement of children and young people in setting up and running services.
There should be a named manager responsible for this area.
32
CURRENT PAEDIATRICS
There is little tradition of genuine consultation in the health service and it is important for service providers to consult with parents and with children. If neither happens then consultation with parents should begin first. Issues for consultation include obtaining feedback on quality issues, obtaining views on new service development and participation in the planning of new services.6
MAKING A DIFFERENCE TO CHILDREN We know that service users value clear guidelines regarding their rights within a service, they value involvement, participation and respect. As health professionals committed to the best interests of children the UN Convention is an invaluable tool which enables us all to support children’s and young people’s development and responsibility for their own health. It requires effort, training and review of practice to ensure that health professionals respect children’s rights. Phillipa Russell comments: ‘Participation skills can be learned and children who are regularly involved in decision making at all levels will be more confident and competent when major decisions are required.’
REFERENCES 1. Alderson P. Children’s consent to surgery. Buckingham; Open University Press 1993.
2. UNICEF State of the World’s Children. Oxford: Oxford University Press, published annually. 3. UN Committee on the Rights of the Child. Concluding observations of the Committee on the Rights of the Child: United Kingdom of Great Britain and Northern Ireland. CRC/C/15/Add.34 1995. 4. Aynsley-Green A, Barker M, Burr S et al. Who is speaking for children and adolescents and for their health at the policy level? BMJ 2000; 321: 229}232. 5. Child Health Rights. Implementing the UN Convention on the Rights of the Child within the health service e a practitioner’s guide. BACCH, Royal College of Paediatrics and Child Health 1995. 6. Hart C, Chesson R. Children as consumers. BMJ 1998; 316: 1600d1603.
FURTHER READING 1. The UN Convention on the Rights of the Child. HMSO 1991. 2. Lansdown G, Waterston T, Baum D. Implementing the UN Convention on the Rights of the Child. BMJ 1996; 313: 1565}1566. 3. Alderson P, Montgomery J. Health care choices making decisions with children. London: Institute for Public Policy Research 1996. 4. Shield J P H, Baum D. Children’s consent to treatment. Br Med J 1994; 308: 1182}1183. 5. Confidentiality and People under 16. Guidance issued jointly by the BMA, GMSC, HEA. Brook Advisory Centres. FPA and RCGP London 1994. 6. Glaser D. In: R. Davie, G. Upton, V. Varma eds. The Voice of the Child e A Handbook for Professionals London & PA 1996; 78d90. 7. Department and Welsh Office (1990) Code of Practice. Mental Health Act, London: HMSO, 1983. 8. Department of Health Children Act Report 1993. London, HMSO, 1994. 9. Russell P, In R. Davie, G. Upton, V. Varma eds. The Voice of the Child e A Handbook for Professionals London & PA 1996; 107d119.
The rights of a child T. Waterston and E. Curtis Consultant Paediatricians, Community Paediatrics Department, Newcastle General Hospital, Arthur’s Hill Clinic, Douglas Terrace, Newcastle upon Tyne NE4 OBE, UK
INTRODUCTION In this paper we hope to illustrate the importance of children’s rights in paediatric practice, to explore the rationale of the UN Convention on the Rights of the Child and its application in UK, and to examine how we can make our practice more child centred, whilst not neglecting the role of parents.
ISSUES FOR PAEDIATRICIANS: WHY IS IT IMPORTANT FOR US? Respect for children and young people’s civil and political rights is integral to the practice of many paediatricians but there is scope for improvement The underlying principle of the 54 articles in the UN Convention is expressed in article 3 stating ‘In all actions concerning children2the best interests of the child shall be a primary consideration’. Important issues include confidentiality, consent, the manner of the consultation, communication and the rights of children in minority groups. Here, we present examples of some of these and look at the principles of management.
CONFIDENTIALITY The right to confidentiality should be explicit and advertized openly in the clinical setting (Article 16). Confidentiality should be breached only if there is a risk to the child concerned, or to another, and this should be made clear to the child from the start. If it is considered necessary to breach confidentiality, the reasons for this should be discussed with the child and he/she should be supported through the ensuing process.
Case study Jane, a 15-year-old, asks you, her GP, to arrange a termination as she is pregnant as a result of
Correspondence to TW.
unprotected sex with her boyfriend. Recently, you have seen her infrequently but knew her as a child and see her mother quite often for anxiety. She asks you not to tell her parents. Jane’s mother has an appointment to see you tomorrow and you know that she will discuss Jane with you as she has been truanting from school recently. This consultation will require time. The pregnancy needs to be confirmed and the father’s views considered; perhaps both partners could be seen together if Jane felt that would be helpful. The GP needs to discuss with Jane the possible options and the consequences of her decisions to have a termination and not to involve her parents. If, following this discussion, Jane is sure that this is what she wants then a reasonable approach is to support her in this.
CONSENT With regard to the issue of consent, Alderson1 has shown that children younger than 10 years old, prepared in an age-appropriate manner were able to give informed consent to orthopaedic surgery. Consent, as defined by the Department of Health and the Welsh Office (1990), needs to be fully informed and freely given, using language which the child can understand. The child must feel autonomous, free to make his or her own choice and should have a simple explanation of consequences which might be difficult to foresee. Article 5 recognizes that parental rights must be exercised in line with the ‘evolving capacities of the child’. The legal issues with regard to consent by children in the UK are not entirely clear. The Family Law Reform Act 1969, the Age of Majority Act (Northern Ireland) 1969 and the Age of Legal Capacity Act (Scotland) 1991 gave young people aged 16 years and over an independent right to consent to surgical or medical treatment. Consent in younger children is governed by the Gillick judgement which established that children under 16 years can give legally effective consent to surgical or medical treatment, independent of their parents’ wishes, provided they have sufficient understanding of their condition and what is proposed.
THE RIGHT OF THE CHILD The practitioner must learn to assess and accept children’s competence. Refusal of treatment is somewhat different and case law has established that if a young person under 18 years chooses to refuse treatment, their wishes may legally be overruled by their parent or carer.
Case study Mark, a 13-year-old, is due for the measles and rubella (MR) catch up immunization which is being given in school. He has not brought a consent form from his parents and the year tutor thinks they may be opposed. However, he had seen the video which was shown about measles and rubella and thinks he should be immunized. The school nurse asks you as the school paediatrician if this is alright as she does not expect to be doing another school session in the near future, and an epidemic of measles has been predicted. Legally it is acceptable to go ahead with the immunization under these circumstances, but may not be wise as it could cause a rift with the parents and the injection is not strictly urgent. The anticipatory approach would be to send out a letter to parents in advance saying that children’s consent may be used and recommending that children discuss this with their parents.
MENTAL HEALTH For child health practitioners working in the area of mental health there are a number of important issues. A mental health consultation is rarely initiated by children making it difficult to consent to the process or to truly participate in it. They are the subject of the conversation and may be embarrassed by open discussion of their shortcomings. In residential or day hospital settings, restraint is sometimes used if a child is disturbed and at risk of causing harm to themselves or others. The manner of this may violate article 19 (‘State parties shall 2protect the child from all forms of physical or mental violence2’). It is helpful to acknowledge the child’s experience of being the subject of the consultation, to acknowledge their relative absence of a voice, to give the child a clear explanation of the status of their involvement and to use appropriate, simple, jargon-free language.
PARTICIPATION At present most staff in the health services have had little discussion of children’s rights issues in their training. Communication with children and young adults is a skill which is only natural to a few people. Managers should arrange regular training sessions for staff groups on children’s rights and communication with children, if
29 possible using the input and experience of young people themselves. Article 12 states the right of children to express views on matters of concern to them and there is need for improvement in how we consult with and involve children and young people in the development of the services provided for them.
Case study You are the school doctor for a high school which has many problems of risk-taking in adolescents, including smoking, alcohol and drug use. Recently there have been several pregnancies in the school. You are asked for your view on how the health services can contribute to prevention and you feel that the view of the pupils should be sought. How would you go about doing this? There are a number of ways in which the views of young people can be sought. In this case, the doctor could either go to the School Council if one exists, or carry out focus groups with different age groups of pupils.
Case study The children’s department of the hospital where you are the clinical director is planning to develop a new facility, for adolescent inpatients and outpatients with chronic health problems. This will be situated in an area adjacent to the outpatient department. The department would like the adolescents who use the hospital to be involved in planning the facility. How would this be brought about? Here, it is important to approach the users of the service. Every young person attending the outpatient department over a specified period could be informed that a consultation was taking place and invited to join a group with a member of staff as facilitator. The ideas presented could be displayed in the outpatient department and comments sought from all users. Other areas which we may not immediately consider include the right of children to non-discrimination (article 2); and the importance of racial awareness training for health workers. Article 23 affirms the right of disabled children to fullest possible social integration. The Children Act Report 1993 noted a wide disparity in the levels of skill and expertise of staff working with disabled children and that it was not a habit to request or record the views of disabled children about decisions affecting their daily lives and futures.
BACKGROUND TO THE UN CONVENTION AND DEFINITION OF CHILDREN’S RIGHTS The idea that children have separate rights is a relatively recent and still somewhat alien concept to many people.
30 The concept of ‘ownership’ of their children comes naturally to parents in most parts of the world. Children are not always seen as a priority group in society and their education, health, growth and mental well-being may suffer as a result of the economic priorities of adults. Children are exploited all round the world, both child labour and prostitution are common and in many countries children are inducted into the army and fight in wars. Children’s rights are not only about consent to operations and confidentiality, important as these are to the practising paediatrician, but there are basic principles to be upheld and global injustices which violate these. The concept of children’s rights was first raised by Eglantine Jebb, the founder of Save the Children in England in the early part of the 20th century. This was a time when child labour and child exploitation were common and child illness was a killer. Children were not regarded as separate persons but as possessions of their parents. Over time, the perception of children has changed greatly to the extent that, in many countries, they now have a highly protected childhood, indeed they are not regarded as adults until they are over the age of 18. Children’s rights were first codified and defined in the UN Convention on the Rights of the Child which is described below. The UN Convention applies to the actions of States. The Convention places children’s rights in a universalist and international context. It behoves paediatricians, in their role as advocates for children, to understand its principles and seek assurance from their governments that it is being implemented. They also need to look at their own work and relationships in the context of the convention. The UN Convention itself had a long gestation before being finally adopted by the United Nations in 1989. It was ratified by the UK government in 1991 soon after the Children Act came into force. The convention has been ratified by all countries in the world bar two, namely Somalia and the USA. The main categories of rights are the rights to survival and development, to free expression of views and freedom of expression, to access to information and to privacy, to protection from all kinds of harm, to good health and education, and protection from exploitation (Box 1). As in the England and Wales Children Act the best interests of the child are recognized as being fundamental in all legislation. However, the Convention is much more wide-ranging than the Children Act. Since October 2000, as a result of the UK Human Rights Act, all legislation in UK must be read and given effect in a way which is compatible with the European Convention on Human Rights (ECHR). This will generally strengthen children’s rights as UNCRC has always been taken into account in decisions by the ECHR. All caselaw decided in Europe will become relevant to the UK, hence for example decisions taken on the placement of children
CURRENT PAEDIATRICS
Box 1 UN Convention on the Rights of the Child E Best interests of the child to be a primary consideration in legislation E Rights to survival and development E Rights to express their views and freedom of expression E Access to information of benefit and protection from injurious information E Protection from violence, abuse and neglect E Right to the highest attainable standard of health E Right to an adequate standard of living E Protection from economic exploitation
in Sweden would appertain to UK. The two relevant articles of ECHR in relation to child health are Article 3 (No one shall be subjected to torture or inhumane or degrading treatment or punishment) which may affect government decisions on legislation concerning corporal punishment, and Article 8 (Everyone has the right to respect for his private and family life, his home and his correspondence) which may affect decisions in relation to social services placement of children (e.g. if a child is not placed for adoption and is on a Care Order then it has to be assumed that the ultimate aim of the plan is for reunification). Hence, the application of the Convention in the UK will require positive action by education departments, social services, juvenile justice, the Home Office and the Treasury as well as by the health departments. Its principles also need to be understood by a wide range of professionals working with children including parents. The issues which still cause difficulty in health care have been outlined previously.
CHILDREN’S RIGHTS: GLOBAL ISSUES The convention has equal relevance in all countries of the world. However, problems such as malnutrition, war, child labour and prostitution, female genital mutilation, homelessness and refugee status are experienced to a much greater extent by children living in the developing world. UNICEF’s annual report, the State of the World’s Children,2 gives graphic illustration of these problems which are in many cases worsening as the gap between rich and poor countries increases. Poverty, in the developing world, caused by the North’s historic economic exploitation of the South, make it impossible for many developing countries to even start applying the Convention. Transnational corporations are often at fault in exploiting child labour and paediatricians as
THE RIGHT OF THE CHILD advocates for child health have a role in pointing out the ill effects of such malpractice.
STATUS OF CHILDREN’S RIGHTS IN THE UK: WE COULD DO BETTER Each ratifying country is expected to report on its progress after 2 years and then at 5 yearly intervals. The UK reported in January 1995 and the UN committee made observations on this report which have been published.3 The committee congratulated the government on the Children Act, on initiatives to reduce Sudden Infant Death and combat bullying in schools, on the Working Together document on child abuse, and on the planned extension of the pre-school education provision. It expressed concern about a number of areas of activity which included: E
E
E
E
E
E
The lack of an independent mechanism to monitor the implementation of the Rights of the Child The absence of mechanisms to prevent the illtreatment of children in Northern Ireland under the emergency legislation The principle of ‘Best interests of the child’ is not reflected in health, education and social security legislation The lack of attention given to the rights of the child to express an opinion, for example, in school exclusion or when parents decide to withdraw their children from the sex education programme Private schools still being permitted to administer corporal punishment The increasing numbers of children living in poverty.
The Children’s Rights Office (CRO), a nongovernmental organization coordinating efforts to promote children’s rights in the UK, urged the government to respond to the recommendations made by the UN committee in advance of the next report due in 1999. In that report, there were improvements noted in the government’s practice but there were still felt to be notable deficiencies. The CRO considers that the most important action would be the appointment of an independent children’s commissioner, or ombudsman, together with a clear government strategy for children and, as exists in other European countries, the appointment of a minister for children. Wales has recently appointed an independent children’s commissioner but this has not yet happened in England. Paediatricians and others have recently highlighted the lack of a voice for children in government in the UK.4 In society at large, such appointments would increase national publicity with regard to children’s interests; would allow children an independent appeal mechanism; and would encourage greater discussion on the requirements of the convention. The expression of
31 children’s views is almost always reasonable and young people make it clear that they would like to work with adults.
ISSUES FOR PURCHASERS AND PROVIDERS Implementation of the UN convention in the health service will require action by purchasers and providers as well as by the Department of Health. The BACCH practitioners’ guide ‘Child Health Rights’5 contains many useful suggestions and should be available to all managers of child health services and to those responsible for commissioning services for children. The main areas in which managers could bring about change are in policy, in training, in the provision of information and in consultation. Policy guidelines should be available for all staff (Box 2). The issues of children’s rights need to be understood and implemented equally by doctors, ward nurses, auxiliaries, receptionists, practice nurses, school nurses, porters, laboratory staff and therapists and guidance should be available, written into contracts and monitored. There should be a review of the written and visual information available for children and their parents. Information should be available for parents and children about the hospital or health centre’s policy with regard to children’s rights so that they know what to expect in relation to the collecting of consent. Information should be available for children, as well as parents, on the commonly occurring conditions, and this information should be at an age-appropriate reading level. If new material is to be developed, young people could assist in preparing and reviewing it. Material should also be available for children and young people whose first language is not English.
Box 2 Guidelines for children’s services Written policy should be made available to all staff who deal with children including guidelines on: E E
E E E
E
Respect for children’s autonomy Availability of age appropriate information on illnesses, conditions, treatments and procedures Children’s consent and refusal of treatment Confidentiality Availability of separate consultation for young people if they wish it Involvement of children and young people in setting up and running services.
There should be a named manager responsible for this area.
32
CURRENT PAEDIATRICS
There is little tradition of genuine consultation in the health service and it is important for service providers to consult with parents and with children. If neither happens then consultation with parents should begin first. Issues for consultation include obtaining feedback on quality issues, obtaining views on new service development and participation in the planning of new services.6
MAKING A DIFFERENCE TO CHILDREN We know that service users value clear guidelines regarding their rights within a service, they value involvement, participation and respect. As health professionals committed to the best interests of children the UN Convention is an invaluable tool which enables us all to support children’s and young people’s development and responsibility for their own health. It requires effort, training and review of practice to ensure that health professionals respect children’s rights. Phillipa Russell comments: ‘Participation skills can be learned and children who are regularly involved in decision making at all levels will be more confident and competent when major decisions are required.’
REFERENCES 1. Alderson P. Children’s consent to surgery. Buckingham; Open University Press 1993.
2. UNICEF State of the World’s Children. Oxford: Oxford University Press, published annually. 3. UN Committee on the Rights of the Child. Concluding observations of the Committee on the Rights of the Child: United Kingdom of Great Britain and Northern Ireland. CRC/C/15/Add.34 1995. 4. Aynsley-Green A, Barker M, Burr S et al. Who is speaking for children and adolescents and for their health at the policy level? BMJ 2000; 321: 229}232. 5. Child Health Rights. Implementing the UN Convention on the Rights of the Child within the health service e a practitioner’s guide. BACCH, Royal College of Paediatrics and Child Health 1995. 6. Hart C, Chesson R. Children as consumers. BMJ 1998; 316: 1600d1603.
FURTHER READING 1. The UN Convention on the Rights of the Child. HMSO 1991. 2. Lansdown G, Waterston T, Baum D. Implementing the UN Convention on the Rights of the Child. BMJ 1996; 313: 1565}1566. 3. Alderson P, Montgomery J. Health care choices making decisions with children. London: Institute for Public Policy Research 1996. 4. Shield J P H, Baum D. Children’s consent to treatment. Br Med J 1994; 308: 1182}1183. 5. Confidentiality and People under 16. Guidance issued jointly by the BMA, GMSC, HEA. Brook Advisory Centres. FPA and RCGP London 1994. 6. Glaser D. In: R. Davie, G. Upton, V. Varma eds. The Voice of the Child e A Handbook for Professionals London & PA 1996; 78d90. 7. Department and Welsh Office (1990) Code of Practice. Mental Health Act, London: HMSO, 1983. 8. Department of Health Children Act Report 1993. London, HMSO, 1994. 9. Russell P, In R. Davie, G. Upton, V. Varma eds. The Voice of the Child e A Handbook for Professionals London & PA 1996; 107d119.