When Molly (not her real name), a 15 year old school girl, came to the practice about her ongoing depression management with her mother, I did not expect that she would be pregnant. Molly had been skipping school because of increasing lethargy, nausea, vomiting, and abdominal pains. Naturally, her mother was growing more concerned about this, and with my GP supervisor’s permission I felt that it was worthwhile doing some blood tests, including a pregnancy test, to exclude some alternate causes.
What could have made issues a little more complicated was the background of her psychiatric diagnosis and the relationship she had with her boyfriend and family. Previously, there had been some issues in the past with her mother who had to be separated from the family for a period of time to their dismay, such that when she returned she seemed to controlling and disempowering to Molly. At the time, their relationship was on the mend with Molly and her mother receiving counselling and psychotherapy. At the time, Molly and her mother had a high degree of transparency in their relationship which was therapeutic in helping her manage her mental health. This made things easier, as there was a mutual acceptance of each others involvement in Molly’s health. However, I felt that some sensitivity needed to be observed during the consult to respect and honour Molly’s rights as a growing and maturing young individual. Perhaps, interviewing the two individually and then bringing them together (what is known as the HEADDS approach to adolescent health) may have avoided such feelings, although it does feel awkward inviting someone to be out of the room and the discussion. This would have been more useful in delineating Molly’s thoughts in confidence limiting any direct influence from her mother.
Molly’s boyfriend had also been faithful to her for the last few years, but was now overwhelmed by the news and is unsure what to do. His parents have tried to stop any contact between their son and Molly, as he is 18 years of age and concerned that he may face legal ramifications (having sexual relations with a minor). And as far as we were concerned, he was not in the picture at this time, even though he would have had responsibility as the potential father of a child. This brought up the issue of father’s rights in deciding issues surrounding pregnancy and childcare, which can often be overlooked.
After further investigation, Molly returned with her mother to discuss her unplanned pregnancy with Dr. Wilson, my GP supervisor, and me. We discussed Molly’s options with a high degree of maturity, weighing up her health, her capabilities to continue on with her pregnancy, options and contacts for medical termination. This was a very ‘human’ discussion with many important and controversial ethical considerations. This was a very comprehensive exploration of all the possible avenues for Molly, her boyfriend, and her family.
Despite being a joint discussion, an assessment of Molly’s competence for consent of medical termination or refusal for treatment of her pregnancy was considered. My understanding of the situation was that the ‘Gillick principle’, where parental consent could be overridden by the child’s decision if they are considered capable and mature enough to make such decisions regarding their own health, would be applied. What was unknown to me was how such maturity could be measured and assessed?
There was no standardised algorithm or manual to deem a young person competent or not. It was purely subjective. Dr. Wilson’s opinion on the matter was that most girls aged 15 or above generally have the capabilities to understand a procedure and its consequences and therefore be able to make a decision accordingly. I reflected what exactly made 15 year olds special, and why the law did not consider this to be the cut-off age for legal adulthood. I was curious as to whether Molly fully understood the consequences of her actions when she (presumingly) consented to have sexual intercourse with her boyfriend, whether she understood the risks that she was undertaking without contraception. As her parents may have thought at the time, “what was she thinking?” This was undoubtedly very difficult to know, as even adults can have unplanned pregnancies and do silly things with their lives. I figured that this was not at all useful for her situation at hand and that it was better not to dwell in her past.
During this session, I wondered whether her mental health issues had any influence on her competency. Had she been where she was two years ago and admitted to a mental institution with loss of insight and self-harm behaviour, and was considered not competent to make decisions as a mature minor then what would happen? Marion’s case came to mind where the convoluted process of seeking power from the parens patriae of Supreme courts is required for consenting process in the child’s best interests (for Marion this involved consent for a sterilization procedure). Would this necessarily apply for Molly? Conventional thoughts in my mind think that Molly did have reasonable understanding of the situation in spite of her mental health. That she was currently controlled on medication and stable in the community setting. Also, that her communication with her parents, in particularly her mother, was sufficient and that a joint decision could be made with the agreement from both parties.
Disappointingly again, the HEADDS approach was not adopted. To an extent, our assessment of her competency did not feel adequate. Fortunately I wondered her mother had an open-mind on the situation and was very supportive towards Molly’s wishes and concerns. However, it would have been very interesting to learn what her mother would have said without Molly being there and to understand her thoughts and feelings about the situation; and to elicit any disparity in opinions. This perhaps, would be something that I have learnt from this experience which I will adopt in future encounters with mature minors in this situation.
In the end, Molly was referred to undergo medical termination for reasons that protected her ‘best interests’. This was a decision that Molly independently reached but was agreed upon by her parents, as she understood the financial, emotional, and physical repercussions the pregnancy may have brought to her life. She figured independently that this would be the best position for her, her family, and her boyfriend. Interestingly, although this may have been in her ‘best interests’, it was by far not ideal.
In the following two encounters I had with Molly, I learnt that living in a small country town with only two high schools, meant that when news leaked, it spread fast. Molly was subject to much discussion at school which exacerbated her mental condition, subsequently causing her to drop out of school. In addition to this, there was the traumatic stress involved with the whole experience which left her questioning whether the decision she made was the right one. Nonetheless, in the time that has past her relationship with herself, her boyfriend, and her parents has dramatically improved.
For me, Molly demonstrated to me the complexities surrounding legal and ethical considerations for mature minors. The principles of respect for the child, competency assessment, liaison with the parents, and application of common law (namely the Gilick test and Marion’s case) are not easy to employ in a case such as this, or indeed for the case of contraception (which for Molly followed not long afterwards). However, the ability to provide transparency between all parties and reach some sort of consensus appeared the most relevant lesson when avoiding litigation. To my mind this seems to be the gold standard of preventing horrible legal mess such as Marion’s case. This is of course very difficult when the child is rendered incompetent, but is worth the thought in more common cases.
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