The next piece was written by Dr David Casey, a North West general practitioner who is currently reading for an LLM in Forensic and Legal Medicine at Lancashire Law School.
The recent media debate over the management of the Ashya King case has raised some salient medicolegal issues regarding the treatment of children. As a clinician, I wonder if my practice as a general practitioner would have been the same as those at Southampton General Hospital.
Much has been discussed regarding the statutory and case law aspects, but what of the professionally binding framework? There has been a perceived increase in the need for child safeguarding training for healthcare professionals recently. All general practitioners are required to have the highest level of training and have a very low threshold to consider child protection issues. The Ashya King case is of a child who has a potentially curable brain tumour, a medulloblastoma, usually treated with total or subtotal surgical resection and chemoradiotherapy. The evidence has borne out that post-operative radiotherapy to the brain and spinal cord increases the survival rate, but only if given within 4 – 6 weeks of surgery. Clearly, after surgery there may be postoperative effects on a child, including an impaired gag reflex and an obtunded cough reflex due to the location of the surgery. The picture is potentially a positive one overall however; curative-intent treatment and a young brain with the potential to demonstrate plasticity and overcome any functional effects of impaired swallowing or airway protection.
The case demonstrates fundamentally that all of us think differently, have different sociocultural expectations, different methods of raising children and different methods of responding to the illness of a child. Most would assume that parents always act in the ‘best interests’ of the child. Working as a practitioner, I can guarantee that this is not the case – people are disparate, have a variety of expectations and beliefs and on occasion these beliefs impact upon their offspring. When there is a difference of opinion regarding treatment options, the law provides recourse for guidance and resolution of these inevitable conflicts. However, in this case, appointing Ashya a ward of the court appears to have been a delayed step. The ensuing transport of a young, post-operative child across Europe with a nasogastric tube in situ and as an unplanned event can clearly be seen to be undesirable. The constant risk of a misplaced nasogastric tube and feeding into the lungs on this long journey was a very real risk, one that undoubtedly would have placed Ashya’s life in jeopardy. As Ashya approached the 4-6 week cut-off for maximum benefit from post-operative radiotherapy, his doctors would have been concerned that his long-term survival was at risk. It was therefore considered that Ashya’s ‘best interests’ are not being served by this unplanned trip across Europe.
This brings us to the reason for the trip – proton radiotherapy, a highly localised treatment for cancer. Ashya was duly considered for this therapy not only locally but supra-regionally and it was felt that based upon the evidence in hand he would not benefit from this treatment. The alternative view must also be considered; conventional irradiation of the brain and spinal cord undoubtedly improves survival as the tumour may have seeded elsewhere. It is not clear that unscheduled proton radiotherapy outside the critical 4 – 6 week window will afford Ashya the same survival benefit.
Should I have been in a similar situation as the doctors at Southampton General Hospital, I would have at all stages attempted to resolve the conflict, involve the High Court and escalate the case as a child protection issue locally. There are plans for proton beam therapy within the UK, but accessing this treatment in the future needs to be timely and planned as well as evidence-based. For now, as doctors, we must follow our professionally-binding guidance from the GMC, ‘Your first concern must be the safety of children and young people.’
Dr David Casey
North West GP
 National Patient Safety Agency, 2011. Patient Safety Alert: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants.
 The General Medical Council, 2007. 0 – 18 years: guidance for all doctors. Para 61