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Children, Families, and Health Care Decision-making
  1. Hazel E McHaffie
  1. Research Fellow, Medical Ethics, University of Edinburgh Deputy Director of Research, Institute of Medical Ethics

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    Lainie Friedman Ross, New York, Oxford University Press, 1998, 197 pages, £30.

    Over recent years in the UK there has been increasing emphasis placed on children taking responsibility for what happens to them. This American publication offers a refreshingly different view of parental and family autonomy and advocates a model of constrained parental autonomy. Ross argues that giving children rights equivalent to those of adults is “to deny them the protection they need” and render them “even more vulnerable than they presently are”. Her thesis is that whilst children should be included in the decision making process, parents should be responsible for their health care even after the children have achieved some threshold level of competency. However, the autonomy of the parents should not be absolute. Rather it should be constrained by a modified principle of respect for persons which takes account of the specific limitations of children's competency.

    The author herself suspects that she will be criticised for not according enough respect to competent children and that her interpretations may permit of wider parental autonomy than many readers will find acceptable. She addresses each anticipated criticism systematically and argues her case cogently and carefully, presenting argument and counterargument, liberally annotating and referencing her text, and pointing out areas where information is scant or questionable. She recognises that parents' conception of what is best for their family may not be what others would perceive as best and that indeed their beliefs and values may even limit opportunities for children. Nevertheless she believes that their autonomy should be questioned only if their decisions are disrespectful of the child's developing personhood; it is not for the state to define ideal parent-child relationships or goals.

    The model of constrained parental autonomy promoted in this scholarly work allows flexibility and breadth of application which, the author contends, makes it practical as a decision making model across a wide range of health care situations. In the second part of the book she tries out the model in various practical contexts: research, organ donation, medical treatment, and adolescent sexual activity. She concludes that it offers a viable alternative to the best interests standard and is particularly useful in situations where interests compete and conflict. Underlying her position is a respect for parents as individuals with their own needs, interests and rights, a fact which she sees as too often ignored. Parental and family autonomy deserve a wider latitude of tolerance than they commonly command.

    This slim volume deliberately invites challenge. The author concludes with the hope that the book will promote dialogue on how health care decisions should be made for children even if readers disagree with her “process or substance”. Many will indeed disagree with some of her thinking, but she should certainly succeed in stimulating debate.

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