Background: By law, the provision of medical treatment to minors in the State of Israel is conditional upon the consent of their parents. In 2004, the Head of the Medical Administration Unit in the Ministry of Health issued Circular No. 4/2004 regarding the treatment of un-accompanied minors in primary care clinics. This circular aims to expand on the law, and permits the treatment of certain minors without parental attendance or consent. The circular does indicate that parents should be notified of the treatment retroactively, and provides cases in which it is possible to avoid notification altogether. The objectives of this study were: (a) to examine the scope of treatment of unaccompanied minors in primary care clinics; (b) to examine caregivers’ knowledge of the provisions of the law and of the circular; and (c) to examine the implementation of the law’s and the circular’s provisions relating to the treatment of unaccompanied minors in primary care clinics in the community. Methods: In a cross-sectional study, we surveyed 158 doctors and nurses from primary care clinics of the Haifa and Galilee districts of “Clalit Health Services”. Respondents were selected via a snowball method, with attention to ensuring a heterogeneous clientele and geographic dispersion. Results: Treatment seeking by unaccompanied minors is an existing and even widespread phenomenon. The vast majority of unaccompanied minors were in effect treated without parental consent. The main reason for minors’ solitary treatment seeking was parents being busy. In 40% of the cases, where minors were treated without the presence and consent of their parents – parents were not notified of the fact. None of the respondents correctly answered all questions regarding the relevant provisions of the law and circular, and only 10% answered all the questions regarding the circular’s parental notification requirements. Conclusions: The Israeli legal arrangement, pertaining to the provision of treatment to minors without the consent of their parents, is vague, unclear to medical and nursing practitioners and limited in terms of the needs of the minors themselves, as well as the needs of the medical system. There is a need for methodical and coherent regulatory thinking on the subject, as well as more thorough education of both nurses and physicians, in order to ensure the rights and interests of minors as well as the rights of their parents. Keywords: Consent to treatment, Children’s rights, Best interests of the minor, Parental notification * Correspondence: email@example.com Michal Perl is based on Mrs. Perl's thesis paper School of Public Health, The Center for Health, Law and Ethics, University of Haifa, Haifa, Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 2 of 7 Background By doing so, so the circular’spreambleattests,it The provision of medical treatment to minors (aged seeks first and foremost to protect the best interests 0–18 year old) in the State of Israel is conditional of minors, by allowing the administration of care, upon the consent of their parents . From this when needed, in cases where the insistence on prior rule, the law precludes simple and ordinary treat- parental consent would serve as an obstacle to good ment, which may be given where parents could not healthcare delivery. be located in a reasonable time frame , as well as The guidelines in this circular do not prevent the care- urgent treatment, which is permissible (and even re- giver from requesting parental consent for treatment in quired) without the consent of the parent – both for any case he deems appropriate. They also do not apply the protection of the particular minor’s best interest to circumstances where specific legal provisions relating and wellbeing . In addition the Israeli law ex- to the treatment of minors exist. The guidelines apply empts two types of treatment from parental consent only to caregivers (doctors, nurses and other caregivers) –minor’s pregnancy termination  and HIV testing in primary care clinics in the community, and not in any  - mainly for the promotion of public health. other medical institution, and only to a minor and his/ Extensive discussion has been conducted over the her family who are familiar to the medical staff in the years – in the academic [5–7], professional [8, 9] and clinic. regulatory [10–12] spheres alike, about the limited scope The Ministry of Health’s circular drafting committee of the exceptions to the parental consent requirements, found that minors aged 14 and over tend to turn to and the need to expand them, in order to promote a primary and routine medical treatment unaccompan- range of goals, primarily the best interests of minors and ied, and that they usually have the intellectual and the rights of minors seeking treatment. This discussion mental ability to understand the information needed has succeeded in somewhat extending the legal recogni- to make a decision and give informed consent to rou- tion of the rights of minors to influence their treatment tine treatments. (for example in allowing a 16 year old minor to veto his Accordingly, the circular distinguishes between a genetic testing , as well as conditioning a 15+ year minor who is over 14 years old and a minor who has old patient’s psychiatric commitment on his additional not yet reached the age of 14 years. This distinction assent  among others). However, the legal obligation corresponds to, and relies on article 6 of the Legal to receive parental consent, for any treatment that does Capacity and Guardianship Act, which allows a minor not fall into such exceptions, remained as comprehen- to preform legal actions, without the consent of his sive as ever. legal representative, “when these are actions that are In light of incomplete attempts to more comprehen- commonly practices be minors of his age”. sibly regulate the treatment of minors and their consent Nevertheless, the circular states that when the care- to treatment, the Ministry of Health attempted to define giver feels that the minor is not emotionally and men- rules of thumb that will help practitioners deal with the tally mature as is expected of his age, he will act as if the dissonance between regulation and the needs of their minor was not yet 14 years old. minor patients. Thus, in 2004, the Head of the Medical The circular attempts to minimize infringing on Administration Unit of the Ministry of Health issued parental guardianship, and states that “the permission Circular No. 4/2004 concerning “visits of minors to pri- to obtain informed consent from a minor over the mary care clinic without the presence of their parents” age of 14 does not intend to lessen the authority of (herein – the circular) . The circular aims to expand the parents, who have full responsibility and authority on the law, and permit the treatment of certain minors over the minor until the age of 18”.Tothataim,the without parental attendance or consent. circular demands that a summary of the minor’smed- ical examination and treatment be at least given to The circular’s provisions the minor in writing for delivery to his parents (and The purpose of the circular, as stated in its preamble, is to in some cases a more prompt phone call to the par- guide caregivers in primary care clinics, in the examin- ents would be in order). However, the circular allows ation, delivery of a diagnosis, recommendations for further the caregiver to act without the knowledge of the tests and treatment of minors in one of two conditions: parents in cases where he/she assesses that parental involvement may harm a minor or when the minor 1. When a minor seeks treatment without an adult strongly opposes his parents’ involvement in treat- escort - alone or with another minor. ment. In such cases, the caregiver must involve a 2. When the minor comes accompanied by an adult Welfare Officer. For minors who are under the age of who is not his parent or guardian (grandfather, 14, according to the circular, the consent of a parent, neighbor, older brother or other). verbally or in writing, is required. Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 3 of 7 As the application of the circular and caregivers famil- or a mixed Arab and Jewish populations (27.2% n 43). iarity with it have hardly been researched, we designed a 46.8% (n 74) of respondents assessed their patients’ survey with three objectives in mind: (a) to empirically socio-economic status as medium-low, while 31% de- examine the characteristics of the unaccompanied mi- scribed their patients as from a medium-high socio- nors seeking treatment (here after unaccompanied mi- economic background, 15.8 (n 25) as from a low socio- nors or UAMs) phenomena in primary care clinics; (b) economic background and 5.1% (n 8) testified that they to examine the acquaintance of relevant caregivers with were mostly serving a high socio-economic population. the provisions of the law and of the circular; and (c) to The response rate veered around 32% (out of 500 examine the implementation of the law’s and circular’s questionnaires distributed by hard copy – which served provisions as they relate to the treatment of minors in as the central surveying method), and a relative small primary care clinics in the community. number of respondents came from rural, predominantly Arab community serving clinics (n.3) – a fact that limits Methods the relevant statistical analysis in our research as well as A total of 158 Israeli physicians and nurses, from pri- its generalizability. mary care clinics of the Haifa and Galilee districts of “Clalit Health Services” HMO, were anonymously sur- Encounters with minors not accompanied by their veyed using snow-ball method – some by a collected parents hard-copy survey and some by Google Docs platform. As described in Tables 1, 74.1% of respondents testified This group was chosen to be surveyed for its heteroge- that they were asked to treat UAMs in the past year. neous cliental and vast geographical dispersion. When asked to estimate the occurrence of UAM in their The survey included questions regarding respondents clinic, most (58.2%, n92) estimated UAMs comprise less demographics, specialty, primary cliental (rural/urban, than 10% of treated minors, while 16.5% estimated them Jewish/Arab/mixed, socio-economic status) their actual to be between 10 and 25% of cases, 4.4% believed they experience with UAMs, their knowledge of the provi- comprised 25–50% of the cases and 5 of the respondents sions of the Israeli law and the Ministry of Health’s cir- (3.2%) testified to over 50% of their minor patients com- cular and on whether they had gone through any ing in unaccompanied. Surprisingly, no significant differ- relevant training. Participants’ acquaintance with the ences were found between rural and urban clinics in Law’s and circular’s provisions where evaluated using minors’ tendency to seek treatment un-accompanied short hypothetical scenarios. For 10 scenarios, respon- (93.1% v. 84.3% respectively encountered the dents were asked to indicate whether the treatment of phenomenon in the last year, p = 0.225); nor between the described UAM was allowed or prohibited, sans par- clinics that serve mostly Arab, Jewish or mixed popula- ental consent. For 6 more scenarios, respondents were tions (all between 82%–87.5%). Socio-economic status asked to indicate whether it was allowed not to (at least was also not found as a significant factor in parental at- retroactively) notify the parents about the minor’s condi- tendance. This lack of significance should be at least tion and treatment. The correct answers to each sce- partly attributed to the small sample of rural and exclu- nario were determined by the expert opinion of 2 sively Arab-population serving clinics. medico-legal experts. The questions and scenarios are The vast majority of UMAs were in-effect treated listed in Additional file 1: Appendix. without parental consent (67% if respondent testified Statistical analysis was done by a professional statisti- that they refused treatment of UMA in less than 10% of cian using SPSS Statistics software, Version 22. such cases). It’s important to note, that most UAMs where in fact Results accompanied by someone – most commonly by grand- One hundred fifty eight questionnaires were analyzed. parents (over 60% of respondents indicated that that was 65% of respondents were nurses. 35% were physicians, the most common scenario). Only 24.2% (n31) thought of them 24 were pediatricians (15.2%), 13 family phy- that minors usually came in alone, when not accompan- sicians (8.2%), 10 general practitioners (6.3%) and 5 ied by their parents. pediatric or family-medicine residents (3.2%). 80.4% When asked as to the most common reasons for the (n 127) of respondents were female; their average age lack of parental presence by the minor’s side, respon- was 47y (±9.09); 67.7% (n 107) were born in Israel dents pointed to the parents being busy as the promin- and 15.8% (n 25) in the former USSR and Eastern ent reason (37% testified to it as being common or very Europe; 80.4% (n 127) completed their professional common). About 35% pointed to a long-standing ac- studies in Israel. quaintance between the minor, his family and the care- Most respondents work in an urban set clinic (77.8%, taker as a recurring reason and 25% identified the par- n 123), serving mostly a Jewish population (66.5% n 105) ents’ perception of the minor as mature enough as a Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 4 of 7 Table 1 Occurrence of Un-Accompanied Minors (UAM) seeking treatment % N (/out of reference group) Encountered UAM in the last year total 74.1 117/158 UAM out of all minor patients Less than 10% 58.2 92 10–25% 16.5 26 25–50% 4.4 7 More than 50% 3.2 5 DNA 17.7 28 Encounter with UAM by socio-economic background low 95 19/20 Chi-Square 4.422, P = 0.219 Low-medium 80.6 50/62 Medium high 90.9 40/44 High 75 6/8 Encounter with UAM by clinic’s cliental Arab 87.5 7/8 Jewish 87.4 76/87 Mixed 82 32/39 Encounter UAM by clinics location Rural 93.1 27/29 P = 0.227 Urban 84.3 86/102 central factor (common or most common). Lack of par- Acquaintance with the law’s and circular’s provisions ental knowledge and the minor’s preference not to be Question 14 of the questioner included 10 scenarios – accompanied were perceived as un-common or rare mo- listed in Additional file 1: Appendix. Participants were tivations (83% and 91.5% respectively viewed it as such). asked to indicate in which of them it was legally allowed Lack of parental knowledge seems to affect Arab- to treat a minor without the presence and/or consent of centered clinics more than others (33.4% of participants his or her parents – whether based on the law’s provi- from such clinics testified that it is a common or very sions or on the circular’s. common reason, as compared to 12% in the predomin- None of the participants responded correctly to all the antly Jewish-population serving clinics); yet no signifi- scenarios, and the average number of correct answers cance can be attributed to that effect. Also, interestingly, stood on 6 out of 10 (with number of correct answers parents being busy was perceived as a rarer motivator ranging between 2 and 9). (for lack of parental presence) in urban clinics, though Physicians were found to be more knowledgeable in is- the small sample of rural clinics (n29/152) did not allow sues relating to pregnancy termination (Mann-Whitney for significance to be measured. U = 1953, p = 0.019). while nurses showed more com- mand of the questions relating to prescription of birth control pills (Mann-Whitney U = 1872, p = 0.020) and to Application of documentation and notification giving a 17 year old authorization to exercise at the gym requirements (Mann-Whitney U = 2033.5, p = 0.018). In all other sce- Sixty nine percent (n 109) of respondents testified that narios - both sectors showed equal partial knowledge. they document the lack of parental presence and con- Question 15 of the questioner included 6 scenarios – sent either always or in most cases, and 51.2% testified also listed in Additional file 1: Appendix, aimed at asses- to also documenting the identity of whoever was present sing respondents commend of when it was permitted to in parents’ stead. 15.8% never or usually don’t document not notify parents of their child’s treatment seeking. any of it, and a staggering 15% (n 24) chose not to an- Only 3.8% of physicians (2/52) and 13.6% of nurses swer the question at all. More importantly, although the (14/103) – merging into 10% of total respondents – cor- circular requires notification of parents in cases where a rectly reacted to all six scenarios, in most cases with no minor is examined and treated unaccompanied, only significant difference between the two sectors. The aver- about 60% of respondents declared that they notify par- age number of correct answers stood on 4 out of 6 (with ents retroactively – always or most of the time – about number of correct answers ranging between 1 and 6). their child’s condition and treatment (usually by a phone It has been shown in the study that there is a direct call). 40% of respondents treat minors without making correlation between receiving training on the subject sure their parents are aware of their medical needs and and the level of knowledge regarding treatment of mi- treatment. nors, yet regrettably, only 41.1% of the respondents Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 5 of 7 claimed that they were in effect trained on this import- slow implementation process, our study’s findings can ant subject. no longer be attributed to that. The data collected in this study reinforces the feeling that the issue of treatment of minors involves consider- Discussion able complexity and suffers from caretakers’ systematic Our Study points to a substantial incidence rate of lack of familiarity with the legal arrangements that regu- UAMs. It is important to note that the incidence rate is late it. based of respondents’ estimation, and not on medical We believe that our study’s results should be generally files review. Another limitation to our study, which may attributed to the sporadic and non-consistent nature of only be remedied by a systematic medical files review, is the Israeli regulation of the treatment of UAMs, and mi- the fact that we did not attempt to collected data regard- nors in general, as well as specifically ascribed to the ing the type of medical problems UAMs presented with complex wording of the 2004 circular . (both in-of-themselves and as compared to accompanied As described before, due to the Israeli parliament’s minors). lack of success in coherently regulating the statues of The most significant finding of the study, in our opin- mature minors in treatment settings, it retorted to anec- ion, relates to caretakers’ lack of familiarity with the dotal solutions, accompanied by somewhat ambiguous current legal situation in Israel. Also, surprisingly, we and limited Ministry of Health’s professional guidelines. saw that in many cases, more nurses correctly responded These solutions further complicate the legal state of af- to scenarios, in which treatment is the sole authority of fairs, confuse the treating staff, and in many cases place physicians – and vice versa. caregivers in absurd situations. A clear and potent example of both these observations For example, as described above, there is no age re- may be found in the scenario describing a minor seeking striction and it is legally permitted in Israel to terminate referral to an HIV antibodies test. The Israeli law has au- the pregnancy of an assenting minor without informing thorized the referral of minors (aged 14 and up) to a her parents. However, it is generally forbidden to sub- blood test for HIV antibodies without the knowledge or scribe the use of contraceptives to a UAM, without her consent of their parents back in 1996 . In 2016, some parents’ permission (unless the minor is well known to twenty years after the enactment of said authorizing the physician, and the prescription is accompanied by regulation, only 52% of respondents were aware of this. retrospective parental notification; or according to a new That is, almost half of them incorrectly answered the Ministry of Health’s circular – if the minor has already question and do not know what the position of the law undergone an abortion in the past ). It is likewise of- is in this case. Furthermore, 94% of nurses answered this ficially forbidden to treat other serious sexually transmit- question correctly, even though they are not the ones ted diseases, such as herpes or syphilis, which cause who give referral for testing. severe pain and mental distress. Ironically, 16-year-olds Also, the Israeli Penal Law of 1977 has since its enact- may serve as volunteer paramedics, as part of their ment permitted pregnancy termination at any age, with- school assignments, making medical decisions and car- out the knowledge of the girl’s parents – if she so ing for others, while in many situations they cannot chooses. In this case (scenario 14.7), too, 47% of respon- make medical decisions regarding their own selves. dents wrongly appraised the legal stance and about 10% Such complex, vague and paradoxical legal conditions claimed that they did not know the answer. may lead to mistaken judgment, impede caregivers, in- Respondents showed greater knowledge of the Israeli crease legal litigation, and most importantly - may pre- law’s emergency exemption to parental consent – as 89. vent adolescents from seeking and receiving well needed 2% of respondents correctly answered scenario 14.5 – treatment. describing a 7 year old UAM, seeking treatment after a The value of involving children and adolescents in fall trauma, while accompanied by his school teacher. their own medical decision-making is increasingly recog- Our findings correspond with the findings of a study nized around the world [19, 20], and minors have been conducted in primary care clinics in the Southern Dis- shown both in Israel and abroad to seek health care un- trict of “Clalit Health Services” in 2008 – The only other accompanied in non-negligible numbers.  Yet, Con- study that had ever been conducted on this issue in trary to the legal trend in other western countries, Israel. In that study approximately 50% of respondents – Israeli law has not yet managed to properly accommo- all physicians, incorrectly answered the questions relat- date these times and needs – at all, and as our research ing to the understanding and implementation of the ar- shows – at least not in an applicable way. rangement regarding the treatment of UAMs . The goal to strive for is to allow for a coherent yet While that early study – conducted only 4 years after age-flexible legislation, adapt to changing times, while the circular’s issue, could be viewed as attesting to a maintaining parental authority. Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 6 of 7 Inspiration for such a coherent regulatory scheme may of Australian common law (Secretary, Department of be found in Canada, in which (with the exception of the Health and Community Services v JWB and SMB (1992) province of Québec) the determining factor in a child’s 175 CLR 218). See also Bird S., Consent to medical treat- ability to provide or refuse consent is whether the young ment: the mature minor, Australian Family Physician person’s physical, mental, and emotional development 2011; 40(3): 159. allows for a full appreciation of the nature and conse- quences of the proposed treatment or lack of treatment Additional file — and not whether or not the person has attained the age of majority.  in some of the Canadian provinces Additional file 1: Question 14: According to the existing law in Israel a default has been set, indicating ability to consent over today, in which of the following scenarios is it permitted to examine and treat a minor without the prior consent of a parent?. Question 15: In a certain age, yet a younger person may still have the which of the following circumstances is it legally permitted not to inform legal authority to consent, with no need for parental ap- the parents of the fact that the minor has been examined and/or treated proval, if in the opinion of a legally qualified medical without their presence?. (DOCX 16 kb) practitioner, he or she is capable of understanding the nature and consequences of the treatment and the treat- Abbreviations ment is in his or her best interests . HMO: Health Maintenance Organization (aka Kupat Holim); MoH: Ministry of Health; UAM: Unaccompanied minors As long as such coherent legislation cannot be achieved, we recommend that the Ministry of Health’s Availability of data and materials circular be Simplified. Also, in light of the findings, The datasets generated and/or analyzed during the current study are not which showed that trained teams where more publicly available but are available from the corresponding author on reasonable request. knowledgeable of the legal requirements – it is import- ant to train the relevant teams on the treatment of Authors’ contributions UAMs and provide them with tools to help them in fu- All authors made substantial contributions to conception and design, been ture dilemmas. involved in drafting the manuscript or revising it critically for important intellectual content. MPR has been central to the theoretical analysis, MP has was also in charge of acquisition of data, and MG was also central to Conclusions interpretation of statistical analysis. All authors read and approved the final The Israeli legal arrangement, pertaining to the manuscript. provision of treatment to minors without the consent of their parents, is vague, unclear to medical and nursing Authors' information Dr. Maya Peled Raz (LLB, MPH, PhD) is a lecturer of law and ethics at the practitioners and limited in terms of the needs of the University Of Haifa, School of Public Health. She is the Chair of the Research minors themselves, as well as the needs of the medical Ethics Review Board (ERB) of the Faculty of Social Welfare and Health Sciences system. at the University of Haifa, the chair of the Ethics Committees at Bnei Zion Medical Center in Haifa and the Galilee Medical Center in Naharia and a Board In order to properly serve the health needs of minor Member of the International Center for Health, Law and Ethics, at the University patients, there is a need for a thorough rethinking and Of Haifa. Michal Perl Karsenty holds a B.Sc. in Life Sciences from Ben-Gurion rewriting of the present legal stance on the delivery of University. She is a Registered Nurse (R.N) and hold an MA in Community Health from the University of Haifa. She works in the Clalit Health Services in minor’s medical care in Israel. Till such coherent the Haifa and Western Galilee districts as a primary care clinic nurse-supervisor. changes are made, the MoH and its partners (mainly Is- Manfred Green MD, PhD is a professor in the School of Public Health, University raeli HMO’s) should invest in the thorough and in-depth of Haifa and is director of the International MPH in Global Health Leadership program. He was previously director of the Israel Center for Disease Control and training of health care practitioners and assist them in a professor in the Faculty of Medicine at Tel Aviv University. relevant decision-making processes. Ethics approval and consent to participate Endnotes The study was approved by the Ethics Review Board at the University of For example, In the UK, Minors older than 16 years Haifa (Approval Number: 161/15). old may consent to their own medical care. Also, ac- Competing interests cording to common law, there are circumstances in The authors declare that they have no competing interests, potential which minors under 16 years of age could consent to competing interests of financial support to declare of. their own medical treatment. In order to do so, the child or young person must have a ‘sufficient understanding Publisher’sNote and intelligence to enable him or her to fully understand Springer Nature remains neutral with regard to jurisdictional claims in what is proposed’. The level of maturity required to pro- published maps and institutional affiliations. vide consent will vary with the nature and complexity of Author details the medical treatment. (Gillick v West Norfolk and Wis- School of Public Health, The Center for Health, Law and Ethics, University of bech Health Authority  1 AC 112.). These princi- 2 3 Haifa, Haifa, Israel. Clalit Health Services, Haifa, Israel. School of Public ples, as established in Gillick, were also endorsed as part Health, University of Haifa, Haifa, Israel. Peled-Raz et al. Israel Journal of Health Policy Research (2018) 7:29 Page 7 of 7 Received: 16 January 2018 Accepted: 25 April 2018 References 1. Legal Capacity and Guardianship Act 1962, Article 14. 2. Patient's Rights Act 1996, Article 15. 3. Penal Law 1977 Article 316b. 4. Detection of HIV in Minors Act 1996, Article 1. 5. Morag T., New Challenges in Defining the Limits of Childhood and Adolescence in light of the International Covenant on the Rights of the Child, Social Security 1995, 44: 108. 6. Kaplan YST. The right of a minor in Israel to participate in the decision making process concerning his or her medical treatment. 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Head of the Medical Administration Unit of the Ministry of Health's Circular 4/2004: Minors' visit to primary care clinic's without an escort. https://www. health.gov.il/hozer/mr04_2004.pdf 16. Hildesheimer G, Orkin A, Biderman B. Visits of minors (ages 14-18 years) at an initial clinic without accompanying a guardian: positions of primary care physicians in the Southern District of the Clalit Health Services. Harefuah. 2010;149:214–8. 17. Orkin Y, Limoni Y, Barak N, Grossman T. Is it permissible to examine a minor who approaches the clinic without a parent? Using an algorithm to examine the Ministry of Health's 2004 circular. Harephua. 2005;144:397–401. 18. Department of Medical Administration circular 8/2017 professional indications for the treatment of girls who apply to pregnancy-termination committees. 19. De Lourdes Levy M, Larcher V, Kurz R. Statement of the ethics working Group of the Confederation of European specialists in Paediatrics (CESP). Informed consent/assent in children. Eur J Pediatr. 2003;162(9):629–33. 20. Katz AL., Webb SA., Informed Consent in Decision-Making in Pediatric Practice COMMITTEE ON BIOETHICS, Pediatrics 2016; 138(2). 21. Bravender T, Price N., English A., Primary care providers' willingness to see unaccompanied adolescents - Journal of Adolescent Health 2004; 34:30–36. 22. AC v Manitoba (Director of Child and Family Services), 2009 SCC 30,  2 SCR 181. 23. See for example: Medical Consent of Minors Act, SNB 1987, c M-6.1.
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