Theoretical Medicine and Bioethics

, Volume 40, Issue 4, pp 279–297 | Cite as

Intervention principles in pediatric health care: the difference between physicians and the state

  • D. Robert MacDougallEmail author


According to various accounts, intervention in pediatric decisions is justified either by the best interests standard or by the harm principle. While these principles have various nuances that distinguish them from each other, they are similar in the sense that both focus primarily on the features of parental decisions that justify intervention, rather than on the competency or authority of the parties that intervene. Accounts of these principles effectively suggest that intervention in pediatric decision making is warranted for both physicians and the state under precisely the same circumstances. This essay argues that there are substantial differences in the competencies and authorities of physicians and the state, and that the principles that guide their interventions should also be conceived differently. While both the best interests standard and the harm principle effectively incorporate important aspects of physicians’ ethical obligations, neither adequately reflects the state’s ethical obligations. In contrast to physicians, the state has major obligations of distributive justice and neutrality that should form an integral part of any proposed ethical principles guiding state intervention in pediatric decision making. The differences are illustrated by examining recent cases involving parental refusal of chemotherapy in aboriginal Canadian communities and parental refusal of blood transfusions by Jehovah’s Witnesses.


Best interests standard Harm principle Pediatric decision making State intervention Liberalism Justice Parens patriae 



I would like to thank audiences at the American Society of Bioethics and Humanities and the Canadian Bioethics Society for comments on presented versions of this paper, and the reviewers and editors at Theoretical Medicine and Bioethics for their helpful comments, insights, and criticisms on earlier versions of this manuscript.


  1. 1.
    Buchanan, Allen E., and Dan W. Brock. 1989. Deciding for others: The ethics of surrogate decision making. New York: Cambridge University Press.Google Scholar
  2. 2.
    Kopelman, Loretta. 1997. The best-interests standard as threshold, ideal, and standard of reasonableness. Journal of Medicine and Philosophy 22: 271–289.CrossRefGoogle Scholar
  3. 3.
    Pope, Thaddeus Mason. 2011. The best interest standard: Both guide and limit to medical decision making on behalf of incapacitated patients. Journal of Clinical Ethics 22: 134–138.Google Scholar
  4. 4.
    Birchley, Giles. 2016. Harm is all you need? Best interests and disputes about parental decision-making. Journal of Medical Ethics 42: 111–115.CrossRefGoogle Scholar
  5. 5.
    Diekema, Douglas S. 2004. Parental refusals of medical treatment: The harm principle as threshold for state intervention. Theoretical Medicine and Bioethics 25: 243–264.CrossRefGoogle Scholar
  6. 6.
    Diekema, Douglas S. 2011. Revisiting the best interest standard: Uses and misuses. Journal of Clinical Ethics 22: 128–133.Google Scholar
  7. 7.
    Gillam, Lynn. 2015. The zone of parental discretion: An ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child. Clinical Ethics 11: 1–8.CrossRefGoogle Scholar
  8. 8.
    Wilkinson, Dominic, and Tara Nair. 2016. Harm isn’t all you need: Parental discretion and medical decisions for a child. Journal of Medical Ethics 42: 116–118.CrossRefGoogle Scholar
  9. 9.
    Kopelman, Loretta. 2005. Rejecting the Baby Doe rules and defending a “negative” analysis of the best interests standard. Journal of Medicine and Philosophy 30: 331–352.CrossRefGoogle Scholar
  10. 10.
    McDougall, Rosalind J., and Lauren Notini. 2014. Overriding parents’ medical decisions for their children: A systematic review of normative literature. Journal of Medical Ethics 40: 448–452.CrossRefGoogle Scholar
  11. 11.
    Beauchamp, Tom L., and James F. Childress. 2013. Principles of biomedical ethics, 7th ed. New York: Oxford University Press.Google Scholar
  12. 12.
    Salter, Erica K. 2012. Deciding for a child: A comprehensive analysis of the best interest standard. Theoretical Medicine and Bioethics 33: 179–198.CrossRefGoogle Scholar
  13. 13.
    McDougall, Rosalind J. 2016. Indeterminacy and the normative basis of the harm threshold for overriding parental decisions: A response to Birchley. Journal of Medical Ethics 42: 119–120.CrossRefGoogle Scholar
  14. 14.
    Bester, Johan C. 2018. The harm principle cannot replace the best interest standard: Problems with using the harm principle for medical decision making for children. American Journal of Bioethics 18(8): 9–19.CrossRefGoogle Scholar
  15. 15.
    Winters, Janine P. 2018. When parents refuse: Resolving entrenched disagreements between parents and clinicians in situations of uncertainty and complexity. American Journal of Bioethics 18(8): 20–31.CrossRefGoogle Scholar
  16. 16.
    Salter, Erica K. 2014. Resisting the siren call of individualism in pediatric decision-making and the role of relational interests. Journal of Medicine and Philosophy 39: 26–40.CrossRefGoogle Scholar
  17. 17.
    Strong, Carson. 1993. Patients should not always come first in treatment decisions. Journal of Clinical Ethics 4: 63–65.Google Scholar
  18. 18.
    Daniels, Norman. 2008. Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.Google Scholar
  19. 19.
    Rawls, John. 1971. A theory of justice. Cambridge: Harvard University Press.Google Scholar
  20. 20.
    Watch Tower Bible and Tract Society. 1961. Blood, medicine and the law of God. Brooklyn: Watchtower Bible and Tract Society of New York.Google Scholar
  21. 21.
    MacDougall, D. Robert. 2010. Rawls and the refusal of medical treatment to children. Journal of Medicine and Philosophy 35: 130–153.CrossRefGoogle Scholar
  22. 22.
    Brummett, Abram. 2019. Whose harm? Which metaphysic? Theoretical Medicine and Bioethics 40: 43–61.CrossRefGoogle Scholar
  23. 23.
    Grant, Kelly. 2014. Ontario hospital cannot force chemo on 11-year-old native girl, court rules. Globe and Mail, November 14.
  24. 24.
    Walker, Connie. 2014. Makayla Sault will not be apprehended by children’s aid. CBC News, May 20.
  25. 25.
    Hamilton Health Services Corp. v. D.H., 2014 ONCJ 603.
  26. 26.
    Eggertson, Laura. 2015. Doctors should collaborate with traditional healers. Canadian Medical Association Journal 187(5): E153–E154.CrossRefGoogle Scholar
  27. 27.
    Guichon, Juliet, Ian Mitchell, Roxanne Goldade, and Victor Lew. 2014. Makayla too young to make medical decision. Hamilton Spectator, May 31.
  28. 28.
    Schafer, Arthur. 2014. First nations children not well served by chemotherapy ruling. CBC News, November 20.
  29. 29.
    Sarah Prince v. Commonwealth of Massachusetts, 321 U.S. 158 (1944).Google Scholar
  30. 30.
    Walker, Connie. 2014. First Nations girl chooses traditional medicine over chemo. CBC News, May 16.
  31. 31.
    Truth and Reconciliation Commission of Canada. 2015. Canada’s residential schools: The legacy. Montreal: McGill-Queen’s University Press.Google Scholar
  32. 32.
    Schwartz, Daniel. 2015. Truth and reconciliation commission: By the numbers. CBC News, June 2.
  33. 33.
    Galloway, Gloria. 2014. Medical system told to examine why aboriginal parents distrust it. Globe and Mail, November 20.
  34. 34.
    Adelson, Naomi. 2005. The embodiment of inequity: Health disparities in aboriginal Canada. Canadian Journal of Public Health 96(Suppl. 2): S45–S61.CrossRefGoogle Scholar
  35. 35.
    Health Canada. 2009. A statistical profile on the health of first nations in Canada: Self-rated health and selected conditions, 2002 to 2005. Accessed September 22, 2018.
  36. 36.
    Wellesley v. Wellesley, 4 Eng. Rep. 1078 (H.L. 1828).Google Scholar
  37. 37.
    Ex parte Crouse, 4 Whart. 9, at 11 (Pa. 1839).Google Scholar
  38. 38.
    Blustein, Jeffrey. 1983. On the doctrine of parens patriae: Fiduciary obligations and state power. Criminal Justice Ethics 2: 39–47.CrossRefGoogle Scholar
  39. 39.
    LaFollette, Hugh. 1980. Licensing parents. Philosophy and Public Affairs 9: 182–197.Google Scholar
  40. 40.
    LaFollette, Hugh. 2010. Licensing parents revisited. Journal of Applied Philosophy 27: 327–343.CrossRefGoogle Scholar
  41. 41.
    Schoeman, Ferdinand. 1985. Parental discretion and children’s rights: Background and implications for medical decision-making. Journal of Medicine and Philosophy 10: 45–61.CrossRefGoogle Scholar
  42. 42.
    Damico, Alfonso J. 1997. What’s wrong with liberal perfectionism? Polity 29: 397–420.CrossRefGoogle Scholar
  43. 43.
    Rawls, John. 2005. Political liberalism. New York: Columbia University Press.Google Scholar
  44. 44.
    Mill, John Stuart. 1956. On liberty. New York: Liberal Arts Press.Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.New York City College of Technology, CUNYBrooklynUSA

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