What are the limits of parental authority? Pediatric bioethics and the law

Abstract

Objectives * Distinguish between the “best interest standard” and “the harm principle” in the evaluation of familial medical decision making in pediatrics and analyze the strengths and weaknesses of each. * Identify key legal cases in pediatrics and explain their impact on practice standards for clinicians providing medical care to children. Understanding the intersection of bioethics and the law is essential for providers caring for complex or chronically ill children. Medical decision making has shifted from a paternalistic model to one in which capitated adults are allowed wide license to make medical decisions for themselves. In adhering to this model, clinicians sometimes have to allow decisions that might be considered “the wrong decision” or a “bad decision,” given the belief that adult patients have the right to autonomous medical decision making. Infants and children lack the ability to make autonomous medical decisions and parents are allowed broad discretion in medical decision making because we believe parents have the right to manage the liberty interests of their children. In our society, we believe it is a parental responsibility to promote their children’s best interests and minimize harms. Parents are given significant leeway to make decisions they believe are consistent with the beliefs and values of their family unit. Children develop maturity to participate in medical decision making as they age, creating a triangle of decision making between patient, parent, and provider, which may raise additional complexities. Respect for the autonomy of the family unit in regard to medical decision making is not absolute. State intervention may be required when parental decision making is perceived to significantly violate a child’s best interest or put them at risk of serious harm. The decision to make a referral to child protective services or to pursue a court order in this context of concern for medical neglect is often distressing to families and providers. Certain paradigm legal cases such as that of Prince v Massachusetts or the Baby Doe cases provide guidance to clinicians who encounter ethical dilemmas while caring for a pediatric patient. Understanding the intersection of bioethics and the law is essential for providers caring for complex or chronically ill children.