The little girl cried while the nurse removed her dressings so that we could inspect her wound. Hidden underneath a hip spica cast, her skin graft donor site had gone horribly septic, and we were trying to remedy it.
An angry, raw site met us. It was no longer sloughing or septic, but it was large and the granulation process was slow.
Our consultant shook his head and said (more to us than to her), “That’s going to need a graft.”
“No!” she cried.
We were surprised. Eight-year-olds rarely voiced opinions about their treatment, especially in our public setting. The only thing they asked for was to go home.
“I don’t want another operation,” she whimpered.
We explained to her that the other option was to stay in hospital until the wound granulated sufficiently. It would mean a longer hospital stay. She had already been in hospital for close-on a year, after being in a horrible MVA that gave her (among other things) two subcapitellar neck-of-femur fractures (hence the spica) and a mangled hand (which necessitated the split skin graft).
“I’ll rather stay longer,” she said. “If you do another skin graft I’ll just have another wound that can get infected.”
She was logical. The fact that there was no mother prompting her was impressive. Of course, she was not necessarily correct. This time she would not have a spica covering the site. This time we would be more careful. But she was still using reason to decide between two options.
Under the South African Children’s Act no. 38 of 2005, children over the age of 12 may consent to medical treatment (provided they are of sufficient maturity) and to surgical treatment with assistance of their parents. So, theoretically, we could have called her parents and gotten consent to do the graft against her will.
But I am glad we did not.
We have legal stipulations – at 12 you have access to contraception, at 16 you can legally have sex (yeah, I know those two contradict one another), at 18 you can drink and drive (not at the same time, of course), 21 makes you financially consentable (is that a word? Anyways, you can sign for financial things) – but real life has more grey areas.
Age and maturity are fluid. Not all 16 year-olds are of the same maturity and cognitive ability. Someone may be competent to make one autonomous choice but incompetent to make a more difficult decision. Even the very concept of childhood is relatively new.
And then, some eight-year-olds can reason about their surgical treatments better than others who are simply afraid of the mask over their face before they are put under.
I loved talking to this child in the wards. She is a bright and intelligent young thing, and it makes me happy to see children like her. It makes me happy to think that she will continue to reason throughout her life, because her (possibly) first attempt at logical reasoning was not squashed by a group of doctors who thought they knew better.