Five ethical frameworks for assessing the permissibility of parental choices around medical care (modified and edited from McDougall and Notini9 and Gillam29)
| Ethical framework | Summary |
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Best Interests Kopelman8 Buchanan and Brock49 | ‘Acting to promote maximally the good of the individual (the child)’ • The state can over-ride the parents’ authority if the child has suffered or is in danger of suffering serious harm • Once that threshold is met, the state must decide on the course of action considering the child’s best interests |
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Harm Principle Diekema7 | Health professionals can seek state intervention if: • The parents’ decision significantly increases the risk of harm • The harm is imminent • The refused intervention is necessary to prevent the harm • The refused intervention is of proven efficacy • The projected benefit to burden ratio of the refused intervention is significantly more favourable compared with that of the parents’ preferred option • No alternative would prevent harm and be more acceptable to the parents • Most parents would agree that state intervention was reasonable |
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The Not Unreasonable Standard Rhodes and Holzman31 | Assess the appropriateness of the decision makers and assess the appropriateness of the decision itself • Centre core judgement: one that is universally made and cannot be reasonably rejected • Second domain judgement: one that is prioritised differently by reasonable people • Third domain judgement: one that can be reasonably rejected An idiosyncratic reason can only be accepted when a patient makes a decision for themselves, not when a surrogate makes a decision (eg, parents). ‘Only decisions based on universal reasons are acceptable for surrogate refusal of highly beneficial treatment.’ |
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Balance of Cost and Benefits DeMarco et al 32 | An economic theory which balances: • Cost of treatment for the patient • Benefit of treatment for the patient • Costs borne by others as a result of the treatment |
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Zone of Parental Discretion Gillam and Kilham et al 29 50 | A practical tool which denotes an ‘ethically and legally protected space’ in which parents are allowed to make decisions for their children. It considers: • The Harm Principle (see above) • The burdensomeness of the intervention Compares the expected harms of acceding to the parents’ wishes with the harms involved in over-riding the parents’ wishes |