När barn säger nej – läkares bedömningar av barns negativa självbestämmanderätt inom psykiatrisk vård

Sammanfattning: In Swedish law, an important main rule is that medical and psychiatric measures cannot be given without consent from the patient. There are exceptions from this rule, f.ex. when treatment is given involuntary under the Act on Compulsory Psychiatric Care (LPT). But as a main rule, patients in Swedish health care have the right to self-determination. To which degree children shall be given the right to consent to or refuse medical or psychiatric treatment is a more complicated question. Issues regarding a child´s personal affair´s normally falls under the guardian's responsibility, while the law also stipulates that children should be given more autonomy in line with age and maturity. The purpose of this paper is to investigate how doctors in child psychiatry understand and assess the child´s right to autonomously refuse treatment and care. How is the law understood and practiced? Are the requirements of predictability fulfilled? 16 doctors in Swedish children and youth psychiatry have been interviewed on the basis of two different scenarios: when the child´s mental disorder is so severe that the conditions for involuntary care under LPT are met, and when the same conditions are not met. The interviews were transcribed and analyzed using qualitative content analysis. The results show that the assessments of the child´s capacity of decision making, and therefore also its right to refuse psychiatric treatment, contains less assessment than expected. Even if the respondents highlight the child´s age and maturity as key factors for the assessment, other factors and arguments are responsible to the fact that the maturity of the child rarely becomes subject to any further investigation. In the situations where the conditions for involuntary treatment are met, it almost always concerns teenagers who are presumed to be mature enough to be recognized the right to autonomous decision making. In the cases where the conditions are not met, the possibilities for the psychiatric care to provide treatment against the child´s will but with support from the guardians are small, regardless of the child´s age and maturity. A possible explanation is that pschychiatric treatment largely require the patient´s involvement to be successful. The reasons that the age and maturity assessment rarely is subject for thorough examination also varies from doctor to doctor, which for example may emphasize different arguments for LPT still to be applied in cases of doubt when the conditions for involuntary treatment are met. This leads to a situation where the application of the law to the exterior may look predictable, but the underlying assessments rests on different grounds.