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发帖数: 42 | 1 https://depts.washington.edu/bioethx/topics/parent.html
Parental Decision Making
Douglas S. Diekema, M.D., M.P.H.
Adult patients have the moral and legal right to make decisions about their
own medical care. Because young children are not able to make complex
decisions for themselves, the authority to make medical decisions on behalf
of a child usually falls to the child's parents.
Who has the authority to make decisions for children?
Parents have the responsibility and authority to make medical decisions on
behalf of their children. This includes the right to refuse or discontinue
treatments, even those that may be life-sustaining. However, parental
decision-making should be guided by the best interests of the child.
Decisions that are clearly not in a child's best interest can and should be
challenged.
What is the basis for granting medical decision-making authority to parents?
In most cases, a child's parents are the persons who care the most about
their child and know the most about him or her. As a result, parents are
better situated than most others to understand the unique needs of their
child and to make decisions that are in the child’s interests. Furthermore,
since many medical decisions will also affect the child's family, parents
can factor family issues and values into medical decisions about their
children.
When can parental authority to make medical decisions for their children be
challenged?
Medical caretakers have an ethical and legal duty to advocate for the best
interests of the child when parental decisions are potentially dangerous to
the child's health, imprudent, neglectful, or abusive. As a general rule,
medical caretakers and others should challenge parental decisions when those
decisions place the child at significant risk of serious harm. When
satisfactory resolution cannot be attained through respectful discussion and
ethics consultation, seeking involvement of a State child protection agency
or a court order might be necessary.
What are some examples of a decision that places a child a significant risk
of serious harm?
Childhood vaccination provides an example of the kinds of factors that must
be weighed in making this determination. While most physicians believe it is
in a child’s best interest to receive the routine childhood vaccinations
and therefore recommend them to parents, they do not generally legally
challenge parents who choose not to vaccinate their children. This is
because in a well-vaccinated community the risk of contracting the vaccine-
preventable illness and suffering harmful consequences from the infection
are quite small. However, this calculation might shift if a clinician is
faced with an unvaccinated child who has suffered a puncture would from a
dirty nail. In the latter case, the risk of tetanus (a serious and almost
always fatal disease if not prevented) has become significant, and the
provider would be justified in seeking the power of the State (through a
court order or involvement of child protective services) to assure that the
child receives the vaccination and treatment necessary to prevent tetanus in
a high risk situation.
What if parents are unavailable and a child needs medical treatment?
When parents are not available to make decisions about a child's treatment,
medical caretakers may provide treatment necessary to prevent harm to the
child's health. In general, a child can be treated or transported without
parental permission if the child has an emergency condition that places his
or her life or health in danger, the legal guardian is unavailable or unable
to provide permission for treatment or transport, and treatment or
transport cannot be delayed without further endangering the child. Providers
should administer only those treatments necessary to prevent harm to the
child until parental permission can be obtained. Examining a child who
presents to medical attention is always appropriate in order to establish
whether a threat of life or health exists.
Should children be involved in medical decisions even though their parents
have final authority to make those decisions?
Children with the developmental ability to understand what is happening to
them should be allowed to participate in discussions about their care. As
children develop the capacity to make decisions for themselves, they should
be given a voice in medical decisions. Most children and adolescents lack
full capacity to make complex medical decisions, however, and final
authority to make medical decisions will usually remain with their parents.
What happens when an older child disagrees with her parents about a medical
treatment?
The wishes of competent older children regarding their medical care should
be taken seriously. If the medical caretaker judges a child competent to
make the medical decision in question, she should first attempt to resolve
the issue through further discussion. If that fails, the medical caretaker
should assure that the child's voice has been heard and advocate for the
child. In intractable cases, an ethics consultation or judicial hearing
should be pursued.
Under what circumstances can minors make medical decisions for themselves?
There are three situations in which minors (those who have not reached the
age of majority in their state of residence) have the legal authority to
make decisions about their health care.
First, every state has emancipated minor laws which designate minors who
meet certain criteria as having the authority to make decisions (including
medical decisions) for themselves. Although emancipated minor laws vary from
state to state, most states recognize an emancipated minor as a person who
meets one of the following criteria:
Economically self-supporting and not living at home
Married
A parent
On active duty in the armed services
Second, most states recognize some minors as sufficiently mature to make
medical decisions on their own behalf. A determination that a minor is
mature usually requires that the minor be older than 14 years of age and
have demonstrated a level of understanding and decision-making ability that
approximates that of an adult. While some states allow physicians to make
this determination, most require a judicial determination of mature minor
status.
Third, all states make condition-specific exceptions to the requirement of
parental consent. These laws may allow an adolescent to seek treatment
without parental consent for sexually transmitted diseases, pregnancy,
contraception, psychiatric disorders, and drug or alcohol abuse.
Is there a resource that summarizes the various state laws regarding
adolescent consent?
The Guttmacher Institute publishes a summary of the adolescent consent laws
that can be found at: www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf |
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