Can Parents Refuse Medical Treatment for Their Child
Minority report: can minor parents refuse handling for their child?
Abstract
Infants are unable to make their own decisions or limited their own wishes most medical procedures and treatments. They rely on surrogates to make decisions for them. Who should be the conclusion-maker when an infant's biological parents are also minors? In this paper, nosotros analyse a case in which the biological female parent is a child. The central questions raised past the instance are whether minor parents should brand medical decisions on behalf of an babe, and if so, what are the limits to this decision-making authority? In particular, tin they reject treatment that might exist considered all-time for the babe? We examine unlike ethical arguments to underpin parental decision-making authority; nosotros debate that provided that minor parents are capable of fulfilling their parental duties, they should have a right to make medical decisions for their infant. We then examine the ethical limits to minor parents' decision-making authority for their children. We argue that the restricted authority that teenagers are granted to make medical decisions for themselves looks very similar to the restricted autonomy of all parents. That is, they are permitted to make choices, but not harmful choices. Similar all parents, small parents must not abuse or neglect their children and must also promote their welfare. They have a moral right to brand medical decisions for their infants within the same 'zone of parental discretion' that applies to adult parents. Nosotros conclude that developed and pocket-size parents should accept comparable controlling authority for their infants.
- children
- competence/incompetence
- controlling
- minors/Parental Consent
- newborns and Minors
https://creativecommons.org/licenses/by/4.0/
This is an open access article distributed in accord with the Creative Eatables Attribution four.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/past/4.0/.
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- children
- competence/incompetence
- decision-making
- minors/Parental Consent
- newborns and Minors
Instance scenario
A 15-year-old girl, M, has a long-standing needle phobia. M falls pregnant, and during the delivery of her term baby, B, refuses to have an epidural anaesthetic and intravenous cannula. This refusal is respected past Thou'south doctors, and the delivery is uncomplicated.
M has been supported during her pregnancy by a teenage parent support group. She is assessed to be capable of caring for B, and B is discharged into 1000's care on the second twenty-four hour period of life. However, on day 7, the baby develops apnoeas and is brought to infirmary by M and her own mother, G, with whom they live. At that place are signs that B has sepsis. Every bit part of his investigation and treatment, the paediatricians plan to insert an intravenous cannula and perform a spinal tap (lumbar puncture, LP) to exclude meningitis.
Grand consents to an intravenous cannula for B and administration of antibiotics. Still, she finds the process so distressing she refuses consent for B to undergo the LP.
B's grandmother supports the medical plan for an LP for B. The child's father, F, who has recently turned xviii, is non registered on the birth certificate, and has not shown an interest in him.
Optimal medical management for B is an LP. This is uncomfortable, but low risk. Without the LP, he volition require a prolonged course of intravenous antibiotics in hospital (at least 2 weeks). If the procedure confirms that B does not have meningitis, he will likely be able to end his intravenous antibiotics and be discharged home after three–5 days. In that location are likewise implications for long-term follow-up.
Should the medical team proceed with the LP against M's wishes (including seeking a court order, if required)? If M or father requite permission, would that suffice?i
Introduction
Rates of teenage pregnancy are falling in Western societies,ane but at that place remain an of import number of children built-in to parents who are themselves non yet adults (in this paper, we will refer to these as 'minor parents')2. In the UK, there are approximately xviii conceptions each year per thousand female minors under the historic period of 18 and 3 per 1000 in minors less than 16.one , 3 Mothers who are minors are more probable to take babies who are premature and or accept low nativity weight; consequently, their offsprings have a greater run a risk of medical issues during childhood.
In many such situations, ethical questions exercise non arise, since minor parents, just as adult parents, are strongly motivated to seek medical attention for their child and accept medical advice. Yet, in some cases, as in the instance to a higher place, conflict may ascend.
There are two questions. First, who should be the relevant decision-maker for the babe? Second, if information technology is the biological parents, what are the limits on minors' conclusion making as parents? Parents are constrained by moral and legal rules protecting the interests of children. But things become more complicated with older minors, who may exist regarded as having developing, rather than fully developed autonomous capacities. What are the implications for this case? Does the fact that M is a pocket-sized change the nature or limits of her moral authority? Should she have the same rights and leeway equally an adult parent in this instance? Our focus in this paper is on the ethical arroyo to such questions.4 We will largely set bated legal questions, acknowledging that the legal arroyo differs in unlike parts of the globe. We volition begin by summarising some of the arguments in favour of parental rights to brand medical decisions for their children.5
Who should determine?
An infant'due south first parents are the biological parents who conceived him or her. Others might acquire parental rights, formally through adoption or courtroom club and informally if the parent freely gives permission for another person to share those duties and that person freely undertakes them.2 In this case, Infant B has a number of persons who might claim parental rights: his mother who is a minor, his father, F, who has now reached the historic period of legal majority, and his grandmother, Thou who is profitable One thousand in her endeavours as a parent.
We are focused on the moral question underpinning the claims to parent B. Three compelling arguments favour permitting Thousand to make decisions for B. An statement based on the duties of parenthood, an argument drawing on the shared consequences of decisions, and a parental-interest justification of child-rearing rights drawing on the value of parenthood.
Duties of parenthood
Parents have duties and obligations towards their children including a duty to promote the interests of the child. These duties are valuable for children, since children are necessarily dependent on adults/parents for their nurturing and protection. But fulfilling this role requires that parents have certain powers and freedoms to brand decisions for their children.3 The ability to consent to or turn down medical interventions forms one of these powers.
In some situations, minor parents are not capable of undertaking the duties of parenthood. After nascence, their infants may be placed in the care of other family unit members or foster carers. However, in cases where a small parent freely undertakes and successfully delivers the duties of parenthood, it arguably follows that they should have the same ability, as an adult parent, to make medical decisions.
In the case above, K was judged capable of making medical decisions for herself during her pregnancy and delivery. She was also assessed to be capable to caring for B, and there is no proposition than B'due south affliction results from a lack of attending or care.
Biological fathers may also uphold duties to their children, and have a correct to make medical decisions. In this case, even so, the biological father (F) has not yet played whatever parental office in the kid's life. If this interruption to his parenthood was through his ain free choice, he has neglected his duties and obligations and consequently forfeited his moral right to make this medical decision.ii ,6
M became meaning every bit a small-scale while in the care of her ain mother. The grandmother, K, has the duties and obligations of a parent towards her daughter Grand and as a consequence has some rights regarding M. Does this extend to decision making for her grandson?
G might take a moral duty to provide emotional, financial and practical help to her daughter, perhaps extending to assist her daughter in making medical decisions. But it is not clear that this requires her to make medical decisions for B or permits her to overrule M. The duty of G towards B is indirect, whereas the duty of Chiliad to B is direct (figure i). Moreover, Thou's controlling rights in relation to M's own medical care are attenuated because of One thousand'southward maturity.
In many circumstances, minor parents may desire the support of their own parents in decision making. If M were to ask her mother to assist with decision making, the grandmother would exist justified in participating in the discussions and helping her daughter to understand the risks and benefits of the LP process. Additionally, information technology might be reasonable for the medical team to appeal to K to assist her daughter in making a decision. All the same, this does not amount to a right to overrule One thousand's refusal.7
Taken together, these considerations suggest that it is M, rather than F or Chiliad, who is the morally advisable decision-maker for B. While parental duties can exist relinquished, at that place is no persuasive reason to think that K has forfeited them.
Shared consequences of decisions
Parents share a portion of the consequences and burdens of medical decisions made for their children. These might be practical, such as additional need to provide intendance or limitations in their life choices, fiscal or emotional (eg, grief or distress at the suffering or expiry of their child). It would seem, prima facie, fair for those who comport the upshot of decisions to at to the lowest degree have some say in those decisions.
For a modest parent who is the master carer of a child, the consequences of decisions bear significantly on her and, as with adult parents, information technology seems reasonable that she makes medical decisions for her kid. Notwithstanding, other family unit members (eg, grandparents) may have similar claims to be involved in decision making.
In the case, 1000 currently lives with and is supported by G. This may mean that Thousand will share in the burdens of decisions (eg, if infant B has a prolonged hospital stay, the need to come back and along to attend the hospital). It is possible that this living arrangement will continue, and in some situations (where K volition exist a primary carer for a long period, or comport the financial costs of treatment) that might give her a moral claim to make medical decisions . However, in many cases, including in this example, it is probable that over time the mother and child will come to live independently of grandparents. Where that applies, it does non seem to give K a strong claim to be the primary medical conclusion-maker for B. If 1000 were a young adult, all the same living with her parents, nosotros would not normally think that the grandparents had a correct to make medical decisions for the grandchild.
Value of parenthood
Some other line of argument proposes that the right to parent is central and that parenting offers a unique good that cannot be achieved in other ways. Brighouse and Swift argue4 that relationships between parents and children have a 'unlike moral quality, brand a different kind of contribution to their flourishing, and so are not interchangeable with other relationships'.4 Given that this relationship is irreplaceable, information technology should be protected.iv 5
Gheaus builds on this view, arguing that adequate parents have the moral correct not merely to parent but to parent their own biological babies by cartoon on empirical realities of pregnancy.vi The infant in this case is merely vii days sometime but Thou has already experienced significant physical, psychological, social and financial costs and may have adult an intimate bail with the baby.6 These features of pregnancy, combined with the value of parenthood forms the basis for the prima facie moral correct for a parent to raise her biological child.
To sum upward, the upstanding reasons to grant parents a right to make medical decisions for their children announced to utilise to minor parents only as they do for adult parents. One difference between minor parents and adult parents is that the duties and burdens of parenthood may exist partly shared (particularly with grandparents). This may give g parents some upstanding claim to have a say in medical decisions, (though arguably this would also apply to some adult parents, where grandparents are heavily involved in the parenting role). However, in most situations, the role of grandparents will be indirect—supporting decisions, rather than making decisions.
All the same, while the shared consequences of decisions might give parents some claim to make decisions, information technology is the child who volition behave the greatest burdens of medical decisions made for him or her. This is ane important reason for limits being practical to decisions that whatever parent can make for their child. Should the limits of parental autonomy differ for a minor parent?
What are the limits to decisions for a minor parent?
If minor parents, like M, are permitted to make medical decisions for their children, should they accept the same range of decisions as an adult parent? To assess this question, it will be useful to first assess the range of decisions adult parents can make for their children. We will compare this with the decisions that mature minors are able to brand for themselves.
The limits for decisions of developed parents
While parents are usually thought to have a right to make decisions for their immature children, no parent can make unlimited decisions for their infants; parents must provide children with basic goods that are necessary for flourishing,7 and they must not abuse or neglect them.
The 'best interests' of the kid are widely accepted equally a fundamental ethical principle for decisions near children.eight 9 Notwithstanding, wellness professionals practise not over-dominion parents whenever they appear to be making suboptimal decisions. Instead, where at that place is uncertainty of issue or where at that place is more than one medically reasonable alternative, the choices of parents are respected, unless the decision for their kid poses a meaning risk of serious harm.x Gild is morally, and too legally, justified to interfere with the parenthood of parents who harm their children.
In paediatric practice, the range of decisions that parents are ethically entitled to brand for their children has been dubbed the 'zone of parental discretion'. Gillam describes this as 'a morally legitimate infinite' betwixt decisions that are optimal for that kid, and decisions that are harmful to the child.eleven
A image example of a suboptimal decision that adult parents are permitted to make is refusal of routine immunisation. It is accepted in nearly societies that parents tin can cull to have their kid vaccinated or not: the decision to vaccinate falls within the zone of parental discretion. There are a range of other suboptimal choices that also fall within the zone of parental discretion.12 , 8
The limits for decisions of mature minors
Should the limits on parental decision making be dissimilar for minor parents? If minor parents are granted decision-making say-so for their infants, it potentially follows that the limits of minor parent's parental autonomy should exist constrained in the same mode as for adult parents. But this question is complicated considering of meaning differences between the ways in which the autonomy of adults and minors are respected.
When adults are asked to make medical decisions for themselves, the principle of respect for personal autonomy is paramount. They can make medical decisions that are unwise or even harmful (at to the lowest degree in terms of refusing treatment; they cannot demand medical treatment). Adults are presumed to have capacity; they must be proven to lack capacity earlier their decisions are justly overruled. A subgroup of adults, without capacity, will have decisions made on their behalf by surrogates.
By dissimilarity, children are assumed to lack capacity. Most decisions are made for them by others, although, a subgroup of minors appear to take the maturity to potentially brand medical decisions for themselves. The ethical basis for such restrictions is principally that respect for developing autonomy of the minor should not extend to decisions that would hazard pregnant harm. This difference is reflected in the legal positions for adults and children. In England and Wales, for example, minors may be deemed to be 'Gillick competent'.thirteen However, where this applies, their choices are more than restricted than adults whose capacity is assessed according to the terms of the.fourteen Minors who are deemed competent by the criteria of the Gillick ruling are permitted to consent to medical treatment but in that location are more than stringent tests of their understanding than adults would face—for example, the wellness profession must be satisfied that they understand 'all the risks'. 2nd, in many jurisdictions they accept limited rights to refuse treatment.fifteen ,9
The limits for decisions of small-scale parents
Which of these frameworks (if either) should constrain a minor parent'south determination making for an infant? That is, should a pocket-sized parent be permitted to brand the same fix of decisions as an adult parent (ie, within the zone of parental discretion) or should she be subject to a more than restrictive framework because of limitations on the decisions minors are permitted to make for themselves?
One reason for holding a 'restrictive' view, is that, as noted above minors are not commonly given the same rights equally adults to make decisions about their own health. If it is justified (for paternalistic reasons) to limit mature minors' medical decision making about themselves, this would presumably utilize even more and so to their decisions for their infants. A minor might be regarded as mature (ie, 'Gillick competent') to make medical decisions on behalf of her infant. Would she be permitted to refuse necessary medical treatments for her infant? She would not exist permitted to refuse necessary medical treatments for herself.
We would fence that information technology is unnecessary to have a divide approach to the limits of decisions for minor parents. That is because the two frameworks are coextensive: the zone of parental discretion and the constrained autonomy of mature minors share the same ethical boundaries. One plausible way of justifying the limits that apply to decisions for mature minors in their own health is on the basis of the impairment threshold. They are deemed to exist able to consent to medical treatment without parental input, partly because health professionals should not be offering handling that would pose a significant take a chance of serious damage. They are not usually immune to refuse treatment where such refusal would be harmful.10
If this is right, information technology appears that the zone of parental discretion that applies to adult parents should as well apply to minor parents. If, in a case like the ane we have described, adult parents would be immune to refuse an LP, information technology would be reasonable to allow M to decline an LP for her infant. On the other hand, if developed parents would be over-ruled, the aforementioned should apply to Yard.
Objections
Variable capacity
1 difference between modest parents and adult parents is that there is a reason to be more stringent in assessing capacity in minors. Children have developing intellectual, emotional and practical skills to make decisions. Decisions are as well situation dependent, thus children may take capacity to brand some decisions, but non others.
In the instance of Thou, her reluctance to consent to the LP considering of her fear of needles might be considered to exist some testify of immaturity. Parents must make difficult and unpleasant decisions on their children's behalf that are in their child's interests. (Nosotros might consider the decision differently if A had refused the LP because she was concerned about the (very) small risk of nerve injury associated with the process.) If M'south decisions to pass up an LP were irrational, that might lead some to conclude that she lacks capacity to make this conclusion, even if she has the capacity to make other decisions nearly her infant's care.
Withal, this conclusion would seem to utilize double standards to minor parents. For example, adult parents sometimes reject immunisation for their kid based on beliefs that have no factual basis or have been discredited.11 Their conclusion might be considered to be irrational, but then long as the conclusion is not harmful to the child information technology is notwithstanding respected. Information technology seems unfair to regard One thousand's decision as not-capacitous, when the same decision in an adult parent would non be over-ruled.
More serious cases
Some may accept that M is entitled to decline an LP for B, perhaps considering the consequences for the baby are relatively small. Simply they may believe that in other, more serious, cases, her conclusion should be over-ruled, though the determination of an adult parent would exist respected.
Consider a variation of the instance. Imagine that B'southward birth has been complicated. There was fetal distress, a delay in delivery and B sustained astringent hypoxic brain damage. The medical team doubtable that B is unlikely to survive and if she survives will be profoundly disabled. They accept counselled M that it would exist in B's best interests to withdraw life sustaining therapies and allow him to die merely M does not agree.
If M insists on continuing life-sustaining treatment, confronting the advice of the medical team, would we allow her to brand this decision? In most situations, for infants with severe hypoxic brain injury, the conclusion about continuation or withdrawal of treatment would fall within the zone of parental discretion.sixteen That is on the basis of the medical and ethical uncertainty about B's outcome and treatment, and the overlap between the interests of the baby and parents.17
Some may feel that given the complexity and gravity of the determination, M should not be expected to brand this decision. After all, it could be difficult for her to understand the brunt of B'southward long-term care needs if he survives. It may be extremely challenging for her to imagine B's (and her own) futurity life, and to weigh up the ethical considerations in the decision nigh life-support.
Withal, this appears to apply equally to many adult parents in this state of affairs. Developed parents may request continuation of treatment, having failed to comprehend (or believe) the infant's prognosis and having failed to weigh up the relevant ethical considerations. In such circumstances, however, adult parents are not usually over-ruled. If the decision falls inside the zone of discretion, their decisions are respected.
It is non clear why this should exist any different for modest parents. It is possible that a parent is then overwhelmed past a kid'south disease that they are unable to make a decision nigh handling. This might utilize to both modest and adult parents. Parents need fourth dimension and support to come up to a conclusion. This, too, would utilize to parents of dissimilar ages. It may also be that the kid'due south condition is so serious that treatment should non continue even if the parents wish this. Notwithstanding, that implies that the determination is outside the zone of parental discretion, and should apply to both developed and minor parents. Given that M is otherwise capable of parenting and given that adult parents are allowed to brand this determination, it appears that M should also exist allowed to make this complex conclusion.
Conclusion
We accept focused on an ethical analysis in this paper, acknowledging that in that location may be important differences betwixt jurisdictions in how these questions are answered.
We accept argued that capable small parents should be medical conclusion-makers for their children in the same style and to the same extent equally capable adult parents. That is because the limits on decisions for minors about their own health are parallel to those that apply to all parental decision making. Capable minor parents should exist permitted to consent to and decline medical treatment within the zone of parental discretion. I significant advantage of this decision is that information technology simplifies assessment of cases like that of M. The aforementioned framework for decisions that applies to adult parents can be used for minor parents. Furthermore, the same approach to assessment of maturity and capacity can be applied equally for decisions that minors might make for themselves.
None of the in a higher place arguments imply that minor parents tin make harmful decisions for their children, nor should bad decisions be blithely accepted. Parents should be supported by health professionals to make skillful decisions for their children. In the case, M should exist counselled, encouraged and supported to consent to an LP for her baby, as this would exist all-time for B. However, her refusal, if it persists, should be respected.
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Source: https://jme.bmj.com/content/46/6/355
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