Medical Ethics- Fraser Guidelines
Fraser Guidelines
The Fraser guidelines are a key UK legal and ethical framework used when deciding whether a healthcare professional can provide contraceptive advice or treatment to a person under 16 without parental consent. They originate from the same landmark case as Gillick competence: Gillick v West Norfolk and Wisbech Area Health Authority (1986), and are named after Lord Fraser, one of the judges in the case.
In medical interviews and UCAT-style ethics questions, Fraser guidelines are often tested alongside Gillick competence, but they are more narrow in scope, applying specifically to sexual health and contraception.
What do the Fraser guidelines allow?
The Fraser guidelines allow a doctor (or healthcare professional) to provide contraception or sexual health advice to a person under 16 without informing or obtaining consent from their parents, if strict criteria are met.
This is a carefully controlled exception to parental involvement, designed to balance:
- Patient confidentiality
- Protection of vulnerable young people
- Public health (reducing unintended pregnancy and STIs)
- Safeguarding responsibilities
The Fraser criteria (must ALL be satisfied)
A healthcare professional can proceed without parental consent if they are satisfied that:
1. The young person understands the advice
The patient must have sufficient maturity and intelligence to fully understand:
- The nature of the advice or treatment
- How contraception works
- Risks, benefits, and alternatives
This is essentially an assessment of capacity in a sexual health context.
2. The doctor cannot persuade the young person to involve parents
The clinician must have tried to encourage the patient to:
- Inform a parent/guardian, OR
- Allow the clinician to do so
If the patient refuses, this criterion can still be met—but the attempt must be documented.
3. The young person is likely to continue or begin sexual activity
The clinician must believe the patient will:
- Continue having sexual intercourse, or
- Begin sexual activity regardless of advice
This ensures the intervention is clinically relevant.
4. The young person’s physical or mental health is at risk without treatment
Without contraception or advice, the patient’s wellbeing may be harmed, for example:
- Risk of pregnancy
- Risk of sexually transmitted infections
- Psychological harm from an unplanned pregnancy
5. Treatment is in the young person’s best interests
The clinician must judge that providing contraception/advice:
- Benefits the patient
- Prevents harm
- Supports overall wellbeing
This links directly to the ethical principle of beneficence.
Confidentiality and Fraser guidelines
A key exam point:
If all Fraser criteria are met:
- The clinician can provide contraception without parental consent
- The clinician must respect confidentiality
- The clinician should not disclose information to parents
However, confidentiality is not absolute.
It can be breached if:
- There is risk of serious harm or abuse
- There are safeguarding concerns
- The patient is being coerced or exploited
In such cases, disclosure may be made to safeguarding teams, but this should be done with minimum necessary information.
Fraser vs Gillick (high-yield distinction)
Even though they come from the same case, they are used differently:
- Gillick competence applies to ALL medical decisions
- Fraser guidelines apply ONLY to:
- Contraception
- Sexual health advice
- STI treatment in this context
A useful interview phrase:
“Fraser guidelines are a specific application of Gillick competence in the context of sexual health.”
Ethical principles behind Fraser guidelines
Autonomy
- Respects the young person’s ability to make informed decisions
- Recognises emerging autonomy in adolescents
Beneficence
- Promotes physical and mental wellbeing
- Prevents unintended pregnancy and STIs
Non-maleficence
- Prevents harm from unsafe or unprotected sex
- Balances risks of secrecy vs harm from disclosure
Justice
- Ensures equal access to sexual healthcare
- Prevents vulnerable groups being excluded from care due to fear of parental involvement
Common interview applications
You may be asked scenarios such as:
“A 15-year-old requests contraception but does not want parents involved. What do you do?”
A strong structured answer should include:
- Assess understanding and competence
- Explore reasons for not involving parents
- Check safeguarding concerns
- Apply Fraser criteria
- Provide contraception if criteria met
- Maintain confidentiality unless risk of harm
High-yield MMI phrases
- “I would assess Gillick competence using the Fraser criteria.”
- “Confidentiality should be maintained if the young person is competent.”
- “I would encourage but not force parental involvement.”
- “Safeguarding concerns override confidentiality.”
- “Best interests of the patient are central.”
Questions and Answers
Here are Fraser Guidelines (Gillick competence) MMI-style questions and answers — very common in ethics stations involving minors, contraception, and confidentiality.
1. What are the Fraser Guidelines?
Answer:
The Fraser Guidelines are criteria used to assess whether a person under 16 years old can be given contraceptive advice or treatment without parental consent. They assess whether the young person is competent to make the decision and whether it is in their best interests.
2. What is Gillick competence?
Answer:
Gillick competence refers to whether a child under 16 has sufficient understanding, intelligence, and maturity to make their own medical decisions without parental involvement.
3. What are the Fraser Guidelines criteria?
Answer:
A doctor can provide treatment without parental consent if all of the following are met:
- The young person understands the advice
- They cannot be persuaded to inform their parents
- They are likely to continue having sexual intercourse with or without treatment
- Their physical or mental health is likely to suffer without treatment
- It is in their best interests to provide the treatment
4. What is the difference between Gillick competence and Fraser guidelines?
Answer:
Gillick competence is a broader concept used to assess whether a child can consent to medical treatment in general. Fraser guidelines specifically apply to contraception and sexual health advice.
5. A 15-year-old requests contraception but refuses to tell their parents. What do you do?
Answer:
I would assess whether the young person is Gillick competent using the Fraser criteria. If they understand the information, are mature enough to decide, and it is in their best interests, I can provide contraception without informing their parents. I would also encourage but not force parental involvement.
6. When can confidentiality be broken in under-16s?
Answer:
Confidentiality can be broken if there is a risk of significant harm, such as abuse, exploitation, or safeguarding concerns. Otherwise, confidentiality should be respected if the young person is Gillick competent.
7. Why are the Fraser Guidelines important?
Answer:
They balance protecting young people with respecting their autonomy. They allow access to confidential healthcare while ensuring safeguarding and safety are maintained.
8. A 14-year-old refuses to tell parents about pregnancy. What do you do?
Answer:
I would assess Gillick competence and ensure the patient understands the situation. If competent, I would respect confidentiality but also provide support and encourage involving a trusted adult. If there are safeguarding concerns, I would escalate appropriately.
9. Can under-16s consent to treatment?
Answer:
Yes. If they are Gillick competent, they can consent to treatment without parental involvement.
10. Can parents override a Gillick competent child’s decision?
Answer:
Generally, no. If a child is Gillick competent, their decision should be respected. However, in some safeguarding situations, clinicians may need to involve senior colleagues or legal processes.
11. What ethical principles are involved?
Answer:
- Autonomy: respecting the young person’s decision
- Beneficence: acting in their best interests
- Non-maleficence: preventing harm
- Confidentiality: protecting trust
- Safeguarding: protecting vulnerable individuals
12. What would you do if you are unsure about competence?
Answer:
I would seek senior advice, reassess understanding, and ensure a supportive environment. Capacity should be carefully assessed rather than assumed.
13. A 15-year-old requests the morning-after pill but refuses to tell parents.
Answer:
I would assess Gillick competence using the Fraser guidelines. If she understands the information, is likely to continue sexual activity, and it is in her best interests, I would provide contraception confidentially. I would also offer support, encourage discussion with a trusted adult, and ensure safeguarding concerns are not present.
14. A 15-year-old patient requests contraceptive advice but asks you not to tell their parents. What do you do?
Answer:
In this situation, I would first ensure I respond in a calm, non-judgemental and confidential environment to help the patient feel comfortable discussing their concerns.
My immediate priority would be to assess the young person’s understanding and capacity to make this decision, using the principles of Gillick competence. I would explore whether they understand what contraception involves, how it is used, and the potential risks and benefits, including protection against pregnancy and sexually transmitted infections.
If I determine that they are able to understand, retain, and weigh up this information, I would consider them competent to make decisions about their own care. I would also explore their reasons for not wanting to involve their parents and gently encourage them to consider whether parental support could be helpful, while respecting their autonomy.
If they remain unwilling to involve their parents, I would then apply the Fraser guidelines, ensuring all criteria are met: that the patient understands the advice, is likely to continue or begin sexual activity, and that their physical or mental health is at risk without intervention. I would also ensure that providing contraception is in their best interests.
If all Fraser criteria are satisfied, I would provide appropriate contraceptive advice and treatment while maintaining their confidentiality. I would explain clearly that, in general, what they discuss with me is confidential, and I would respect their wish not to inform their parents.
However, I would also assess for any safeguarding concerns, such as coercion, abuse, or exploitation. If any concerns arose, I would escalate appropriately to safeguarding teams, sharing only necessary information to protect the patient.
Overall, my approach balances respect for patient autonomy, confidentiality, and beneficence, while ensuring patient safety and adherence to UK legal and ethical guidelines.
Useful Links
https://www.nhs.uk/conditions/consent-to-treatment/children/
https://www.nhs.uk/conditions/consent-to-treatment/children-under-16/
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/0-18-years
https://www.nice.org.uk/guidance/ng55
https://www.legislation.gov.uk/ukpga/1989/41/contents
https://www.gov.uk/government/publications/consent-theory-and-practice
https://www.medicalprotection.org/uk/guidance/consent/children-and-young-people
https://www.cqc.org.uk/guidance-providers/healthcare/consent-care-treatment