What is the stance on children’s autonomy? How much involvement should a child have in a personal health-related decision? In “The Place of Autonomy in Bioethics,” Childress writes that “the presence, absence or degree of autonomy is a morally relevant characteristic” (Childress 312). This means that if we are deciding on the level of autonomy for a child, leaving them no opportunity for autonomous decision-making could be a possible violation of respect for autonomy.
Chlidress frames it perfectly: “Complexity of respect for personal autonomy.” In children especially, there is a huge grey area for making autonomous decisions with respect to healthcare. In 1995, the American Academy of Pediatrics released recommendations for pediatric decision-making. The AAP divided children into 3 levels of capacity: lacking, developing, and having capacity to make health-related decisions (Ross). The main guidelines regarding children with less capacity for making decisions include “seeking parental permission,” seeking “third-party mediation for parent-child disagreement,” and overruling the child’s decision if it goes against life-saving treatment. This seems fair, assuming that the child is inexperienced in life, unprepared to make an informed decision, and the parent makes a well-informed decision that is in the best interest of the family. For more mature children, the parent becomes a consultant rather than a consenter (Ross).
The major issue with the AAP recommendations is that no guidelines or tests exist to determine the level of decision-making capacity of a child! This means that the physician or pediatrician is the one who decides whether the parent will be a consultant or a primary decision-maker. Of course, if the parent makes a decision that is “abusive or neglectful,” the pediatrician can overturn that decision (Ross). Also, hospitals normally have an ethics committee that handles these kinds of situations, and issues are dealt with on a case-by-case basis.
Another important point to note is that people exist in and through time and their choices and actions occur over time” (Childress 310). A parent may be the primary decision-maker, but the parent must also think about the child’s future- will this child be happy in the future with the decision the parent made? Could this be a violation of autonomy if the child opposed the parent’s decision? What if the child was at an age that the degree of autonomy was sufficient, but the child’s opinion was still ignored? Childress supports this idea by stating “we also have to put that patient’s present consents and dissents in a broad temporal context encompassing both the past and the future” (Childress 310). Veatch argues against allowing the parents full consent, because they may not actually have the child’s best interests in mind- they think about money, parental obligations and their other children, among other things.
We must not abandon personal respect for autonomy, even in the situation that the patient is a child. A final decision should be balanced and thoroughly discussed and understood by all who are involved. Coercion or force should only be used as a last resort (Ross). In “Abandoning informed consent,” Veatch says “it would be extremely difficult to determine whether the absolute best choice has been made” by the parent, but after reading these articles I believe their decision should be considered above the child’s or the physician’s opinion.
References:
Childress, James F. “The place of autonomy in Bioethics.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 308-316. Print.
Ross, Lainie Friedman. “Health Care Decisionmaking by Children Is It in Their Best Interest?” The Hastings Center Report. 27.6. (1997): 41-46. Blackwell Publishing Ltd. Web. 23 Feb 2014 http://dx.doi.org/10.2307/3527717.
Veatch, Robert M. “Abandoning informed consent.” Arguing About Bioethics. By Stephen Holland. London: Routledge, 2012. 317-328. Print.
http://www.wordle.net/show/wrdl/7588721/Wordle_Children_autonomy created by Jackie Glodener. 24 Feb 2014.
This is definitely a really complicated situation because at what point does the child become “old enough” to make his or her own decisions?
When a child isn’t old enough to see the benefits and consequences of a medical decision, I don’t think he or she should be making the decisions, and the decision should be up to the physician or the patient. I think that the decision for a child should be made as a joint effort between physician and patient because while the physician has an objective point of view, the parent has a subjective point of view on the child. Therefore, it would be beneficial to have both of these perspectives when making decisions for the child.
However, if the child is old enough where he or she can make a rational distinctions between the benefits and consequences of a medical decision, he or she has a right to autonomy and the doctor and parent should respect the autonomous decision. If the parent or physician has a problem with the child’s decision, then they could easily explain why the child may be in the wrong. If the child actually isn’t old enough and mature enough to battle this argument, then clearly his or her autonomy should be overrode by the parent or the physician.
This is a very complicated matter and it’s interesting that you brought this up. At what age do we let children make their own decisions? Is there a specific age limit? Some ten-year olds are way more mature than others. How do we distinguish what’s rational enough to listen to the child?
Every good parent wants to do what’s best for their child, but sometimes, as you have mentioned, parents are juggling other responsibilities that weigh in on their decisions for their child. This should be a very important evaluator on whether or not the parents are making the best decision for their child. Then there is the issue with how old a child has to be to make rational decisions. Interestingly, the current legal age is 18 even though the human brain (especially the frontal lobe, where the reasoning and decision-making occurs) doesn’t completely develop until about 25 according to this article: http://www.academic.marist.edu/mwwatch/fall05/science1.htm. If we were making the case that we need have a fully developed reasoning center, then “children” 25 and under cannot make fully rational decisions and therefore are not capable of being autonomous in deciding a treatment. This, however, sounds a bit far fetched. Of course, the parent and pediatrician should have the ultimate say for treatment in young children, but older children in their mid to late teens should at least have say in their treatment and explain to parents and pediatrician why they have chosen that option. The pediatrician and parents could then explain why they would rather implement another plan, if necessary. Essentially, there should be an open dialogue between the three parties so that at least the parents and pediatrician know what the child’s interest are and hopefully act in a manner that includes these interest so that the best option for the patient can be obtained.
I think that for an infant, it is clearly that the parent(s) should be making all medical decisions for their child, under the guidance and advice of the physician. Similarly, for a young child, at least until age 8-9, the parent and doctor should be making all decisions jointly. When the child reaches double digits, however, is where uncertainty enters. To some extent, the is when “mature” children appear. While these children may seem advanced for their age mentally, I think parents and the healthcare provider should be making the bulk of the decisions with some in-put from the child. I hold the same plan for the so-called “mature” children as well because no matter how mature they are, no 10 year old enjoys shots or yucky tasting medication. As the child approaches adolescence, it would make sense for the doctor, parent, and child to make decisions jointly, as the patient by this point has a basic understanding of the biology, if not the mechanics. When the child reaches the age of 15-16, however, I believe the decision making returns to a two way street, featuring the doctor and the child, with the parent’s input, should the patient desire it. According to this website which serves to answer questions teen may have about doctor visitations, http://www.healthychildren.org/English/ages-stages/teen/pages/Information-for-Teens-What-You-Need-to-Know-About-Privacy.aspx, teens are told that they are allowed to speak to the doctor alone whenever they ask. The only legal happenstance keeping parents in the loop is the fact that they can access the child’s prescription information until the child reaches 18.
I don’t agree with your stance that the parents’ decision should be considered above the child’s or the physician’s opinion in every case. Sometimes the parents do not understand what is medically best for the child and do not realize the consequences their actions can have. While I was shadowing a pediatric endocrinologist, I saw many cases of congenital hypothyroidism, which is a condition that affects the thyroid’s function. The gland plays a crucial role in mediating growth, brain development and metabolism. These processes are imperative for normal maturity in newborns, without proper regulation the child can become mentally challenged and develop physical disabilities. The endocrinologist told me that sometimes parents do not give the child his or her medication. At this time, the physician calls social services to investigate the situation of the family. In this extreme case the physician’s opinion overrides the parents’ decision/action for the sake of the child’s wellbeing.
This is a grey area for sure- another example that addresses a fault in this argument for autonomy is a case where a both a parent and child want to opt out of a vaccine. The child may not want it because the needle is frightening, and the parent may not want it because they are misinformed about its risks. This can be a grey area as it superficially seems agreeable but is not, in addition to the case being preventative care instead of emergency care. I appreciate you mentioning the timeline of the child’s life as well. The portion of life spent in childhood is short, yet crucial in determining the health of the person for the rest of their life. In fact, studies have even showed nutrition of the mother while the baby is in the womb affect the baby’s future eating habits!
As long as the child is a dependent and reliant on financial assistance from their parent then they still classify as a minor. As a parent it is their role to care about what’s best for the child, so they should be a factor in the situation when deciding on treatment. However, to establish the child’s autonomy, they should also have a voice in the matter by expressing how the feel about the treatment. For example, there was a movie where a child was trying to earn the right to her own body because her mother was taking too much bone marrow and giving it to her sister. Her sister told her to stop because it was her time and she saw how much it hurt her sister. The mother’s goal was focused on the sister that was about to die so much, that she wasn’t even thinking about the damage she was doing to her other daughter. This is an example of bad parenting and communication. The parent along with help from the physician should be able to make a call based off of their best judgment, but the parent does need to consider what the child wants as well. In the movie the child wanted right to her body, so her other sister could die in peace. Difficult decisions like these are when emotions come into play, and it’s hard to incorporate the parents thought because they may not be thinking about what’s best for the child. They may be just thinking that they want their daughter to live.
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