Intervention principles in pediatric health care: the difference between physicians and the state
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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.
KeywordsBest 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.Buchanan, Allen E., and Dan W. Brock. 1989. Deciding for others: The ethics of surrogate decision making. New York: Cambridge University Press.Google Scholar
- 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
- 6.Diekema, Douglas S. 2011. Revisiting the best interest standard: Uses and misuses. Journal of Clinical Ethics 22: 128–133.Google Scholar
- 11.Beauchamp, Tom L., and James F. Childress. 2013. Principles of biomedical ethics, 7th ed. New York: Oxford University Press.Google Scholar
- 17.Strong, Carson. 1993. Patients should not always come first in treatment decisions. Journal of Clinical Ethics 4: 63–65.Google Scholar
- 18.Daniels, Norman. 2008. Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.Google Scholar
- 19.Rawls, John. 1971. A theory of justice. Cambridge: Harvard University Press.Google Scholar
- 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
- 23.Grant, Kelly. 2014. Ontario hospital cannot force chemo on 11-year-old native girl, court rules. Globe and Mail, November 14. http://www.theglobeandmail.com/life/health-and-fitness/health/cancer-patient-has-right-to-use-aboriginal-healing-instead-of-chemo-judge-rules/article21587859.
- 24.Walker, Connie. 2014. Makayla Sault will not be apprehended by children’s aid. CBC News, May 20. https://www.cbc.ca/news/indigenous/makayla-sault-will-not-be-apprehended-by-children-s-aid-1.2648562.
- 25.Hamilton Health Services Corp. v. D.H., 2014 ONCJ 603. http://canlii.ca/t/gf8sg.
- 27.Guichon, Juliet, Ian Mitchell, Roxanne Goldade, and Victor Lew. 2014. Makayla too young to make medical decision. Hamilton Spectator, May 31. http://www.thespec.com/opinion-story/4550627-makayla-too-young-to-make-medical-decision.
- 28.Schafer, Arthur. 2014. First nations children not well served by chemotherapy ruling. CBC News, November 20. http://www.cbc.ca/news/aboriginal/first-nations-children-not-well-served-by-chemotherapy-ruling-arthur-schafer-1.2836141.
- 29.Sarah Prince v. Commonwealth of Massachusetts, 321 U.S. 158 (1944).Google Scholar
- 30.Walker, Connie. 2014. First Nations girl chooses traditional medicine over chemo. CBC News, May 16. http://www.cbc.ca/news/aboriginal/first-nations-girl-chooses-traditional-medicine-over-chemo-1.2644637.
- 31.Truth and Reconciliation Commission of Canada. 2015. Canada’s residential schools: The legacy. Montreal: McGill-Queen’s University Press.Google Scholar
- 32.Schwartz, Daniel. 2015. Truth and reconciliation commission: By the numbers. CBC News, June 2. https://www.cbc.ca/news/indigenous/truth-and-reconciliation-commission-by-the-numbers-1.3096185.
- 33.Galloway, Gloria. 2014. Medical system told to examine why aboriginal parents distrust it. Globe and Mail, November 20. https://www.theglobeandmail.com/life/health-and-fitness/health/medical-system-told-to-examine-why-aboriginal-parents-distrust-it/article21686603.
- 35.Health Canada. 2009. A statistical profile on the health of first nations in Canada: Self-rated health and selected conditions, 2002 to 2005. http://www.hc-sc.gc.ca/fniah-spnia/alt_formats/pdf/pubs/aborig-autoch/2009-stats-profil-vol3/2009-stats-profil-vol3-eng.pdf. Accessed September 22, 2018.
- 36.Wellesley v. Wellesley, 4 Eng. Rep. 1078 (H.L. 1828).Google Scholar
- 37.Ex parte Crouse, 4 Whart. 9, at 11 (Pa. 1839).Google Scholar
- 39.LaFollette, Hugh. 1980. Licensing parents. Philosophy and Public Affairs 9: 182–197.Google Scholar
- 43.Rawls, John. 2005. Political liberalism. New York: Columbia University Press.Google Scholar
- 44.Mill, John Stuart. 1956. On liberty. New York: Liberal Arts Press.Google Scholar