2025 – PAGE 445 – ETHICS IN PEDIATRICS
CONSENT
Based on the right to autonomy, a competent person must consent to be treated. Valid consent requires the patient to understand the treatment, including the risks and benefits. Therefore, it is vital to give the patient (or family) that information in a clear and understandable way and to be sure it is understood. The physician must explain the treatment options with their risks and benefits so that the patient (or parents) can make an informed decision. Physicians cannot simply make the decision based on their own judgment.
The reasonable person standard says that you must tell the patient all the information that any reasonable person would want to have in order to make the decision.
Implied consent is a standard applied when there is urgent need for treatment but no time for true informed consent. Life-saving treatment on a child before there is time to obtain consent from the parents would fall into this category.
PERMISSION
Minors and others not competent to make their own medical decisions need someone else to decide for them. Technically, this is called “permission” and not “consent,” since only the person himself can consent to treatment. It is almost always the parents who have the right to make decisions on behalf of their children, though sometimes it is the court or a court-appointed guardian.
When the parents do not want their child to have a medical treatment which the doctor feels is important, the parents have the final word unless there is an immediate, substantial risk of serious harm, suffering or death which would likely be avoided with treatment. For example, vaccine refusal is not considered medical neglect because the risks are relatively low. On the other hand, parents would probably not have the right to refuse antibiotics for their child with meningitis.
PEARL: If you have an exam question where the parents are opposed to the “correct” medical course of action, the correct answers could involve trying to reason with the parents, listening to their point of view in order to build rapport, or following their wishes. Jumping straight to treating the child against their wishes will NOT be the answer. If there is a significant risk of serious harm, then involving child protective services or the court system could also be correct.
RELIGIOUS, CULTURAL, AND PERSONAL OBJECTIONS
What if the parent’s objections to treatment are based on religion? Does this make the objection stronger or weaker? It doesn’t do either. A believer in Christian Science might refuse to allow his child to receive a transfusion based on religious beliefs, while another parent might refuse without any religious reasons at all. Your decision to respect or appeal the parents’ wishes should not be based on the presence or absence of religious or cultural beliefs, but only on the likelihood of serious bodily harm, suffering, or death if the treatment is refused.
Respect for people includes being respectful of their religious, personal, and cultural beliefs. That means that the physician should understand and consider those beliefs in situations where they might conflict with the medical best interest of the child. Discussion that acknowledges the parents’ or patient’s beliefs, values, or fears are going to have a much better chance of solving a conflict than will confrontation.
ASSENT
The idea of assent is that children should be respected as individuals and should play a part in the medical decision making. The key things to remember are (a) the child can be involved to some degree from a very early age, and (b) the nature of the involvement depends greatly on the child’s level of maturity and other characteristics such as life experience. For example, a preschool child receiving an injection could be allowed to choose which side to be used, right or left, and the design of Band Aid. At the other extreme, a mature 15-year-old with a chronic illness might be actively involved along with her parents and doctors in making important treatment decisions.
For exam questions which hinge on how much to involve a child in treatment decisions, choose the one which seems to give as much consideration as possible to the child in line with his or her maturity level. On the other hand, the parents still have the final word.