Ethical question

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Here, we would be required to report to Child Protective Services and the matter would go to a judge.
 
sindadel said:
Here, we would be required to report to Child Protective Services and the matter would go to a judge.
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👍 This.

This just happened in MN. A 13 year old kid needed chemo, and the parents and kid wanted to try some alt med thing, and a judge ordered him to get chemo.

If it's an adult, they have a right to refuse, but a child...no. You can try to respectfully reason with the family, but in a life or death situation the law is on your side and you are pretty much obligated to treat.
 
reidmike said:
What if it were an emergency and needed immediate care?
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They can be placed into emergency protective custody. The hospital police can come up and arrest the parents if they try to interfere
 
They call the judge even in the middle of the night. If it is a life/death situation, you act and face the consequences later.
 
I know they'll try to pin this as an ethical question, but it's really not... it's a legal question. Since I'm not familiar with the law, I'd tell the interviewer that I would have to become familiar with the law and do whatever the law says.
 
Call the legal department.
Ethically I think forcing treatment is okay in this case. Adults can decide to die for their religious beliefs, but they can't decide to kill their children for those beliefs.
 
In all cases of emergency, government's interests in protecting a minor's life exceed the right of parent to give consent. Parents can refuse in their own case but not for the child.
 
Forced treatment is generally considered legal in cases of apparent child negligence (in the eyes of the law).


Here's my question: At one point does forced treatment become legal? For example (and I'm totally making this off the top of my head, so it might not even be legit): A minor suffers from a serious psychiatric disease to the point that he is a potential danger to himself and/or those around him, but the parents refuse anti-psychotics or other drugs used in a psychiatric situation (don't Scientologists refuse psychiatric txn?). Can treatment be forced here? I suppose there's not an "immediate" peril, but there is a strong potential for it. Where does the law fall?
 
According to one of my professors, any time 2 physicians choose to do so they can essentially take a child away from its parents and give care.
 
If I could go my own way and if the child also refused care, I would respect that decision. However, hospital policy and legal regulations probably wouldn't let me go my own way.
 
As far as I know, it's very hard to get in trouble for treating someone when someone else says they shouldn't be treated. But you might get in trouble for allowing a minor to die because his/her parents wanted to refuse treatment on the child's behalf.
 
Ethically, I would want a psychiatrist to ascertain the level of competency of the 13-year-old to potentially decide for himself (if he refuses tx). Unfortunately, legally this is imprudent because the law says all 13-year-olds must be treated exactly as children. Most 13-year olds are probably not competent, but there are 18-year-olds out there less mature than some 13-year-olds. Essentially, age-based standards are arbitrary, but I guess they make life simpler, though not always more ethical.
 
scotsdoc54 said:
Forced treatment is generally considered legal in cases of apparent child negligence (in the eyes of the law).


Here's my question: At one point does forced treatment become legal? For example (and I'm totally making this off the top of my head, so it might not even be legit): A minor suffers from a serious psychiatric disease to the point that he is a potential danger to himself and/or those around him, but the parents refuse anti-psychotics or other drugs used in a psychiatric situation (don't Scientologists refuse psychiatric txn?). Can treatment be forced here? I suppose there's not an "immediate" peril, but there is a strong potential for it. Where does the law fall?
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Seeing as docs can commit an adult against his or her own will based on potential danger and that parental consent is often viewed as "weaker" than personal adult consent, I think the law in this case would strongly favor forced treatment of the child.
 
LiveUninhibited said:
Ethically, I would want a psychiatrist to ascertain the level of competency of the 13-year-old to potentially decide for himself (if he refuses tx). Unfortunately, legally this is imprudent because the law says all 13-year-olds must be treated exactly as children. Most 13-year olds are probably not competent, but there are 18-year-olds out there less mature than some 13-year-olds. Essentially, age-based standards are arbitrary, but I guess they make life simpler, though not always more ethical.
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This is not entirely true. Yes, all 18 year olds are treated as equally competent adults (with the exception of mental handicaps) however, younger people can be "upgraded' to a higher level of competency. An example of this would be emancipated minors, who are allowed to live independent of guardians. Also, in the case of the MN kid whose parents didn't want to give chemo, the judge tried to determine the kid's ability to make the decision for himself. Supposedly, the kid was also refusing treatments based on religious grounds, but he couldn't demonstrate any kind of knowledge of his religious beliefs. Hence, the judge said the child did not truly understand his religious beliefs and/or the consequences of his actions and therefore he could not refuse the treatment himself, and he ordered the chemo be given. Of course, all this competency (and I'm not sure we are even using that word correctly, but whatever) testing and determination takes forever and a day so it really isn't applicable in emergent situations.
 
What if the patient was a Jehovah's Witness?

If I am confident that the child displays a reasonable adult's level of competency and refuses treatment, I would follow their wish. Religious beliefs can transcend scientific reasoning, and often provide a deeper meaning to life than one who only follows science can understand. I would not have the child live by violating a serious belief and all the consequences that may result.

If however, the child is unsure about their committment to the religion, I would assume that it is in their best interest to survive, and disregard what the parents feel about it. I will carry out my duty to preserve life and proceed with the transfusion.
 
cbear said:
👍 This.

This just happened in MN. A 13 year old kid needed chemo, and the parents and kid wanted to try some alt med thing, and a judge ordered him to get chemo.

If it's an adult, they have a right to refuse, but a child...no. You can try to respectfully reason with the family, but in a life or death situation the law is on your side and you are pretty much obligated to treat.
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That story made me so upset. Especially when they told all the stories of how the last time the kid was on chemo he felt a ton better, but then they refused to let him have it anymore... Ugh. I hope he's doing ok.
 
scattun said:
This is not entirely true. Yes, all 18 year olds are treated as equally competent adults (with the exception of mental handicaps) however, younger people can be "upgraded' to a higher level of competency. An example of this would be emancipated minors, who are allowed to live independent of guardians. Also, in the case of the MN kid whose parents didn't want to give chemo, the judge tried to determine the kid's ability to make the decision for himself. Supposedly, the kid was also refusing treatments based on religious grounds, but he couldn't demonstrate any kind of knowledge of his religious beliefs. Hence, the judge said the child did not truly understand his religious beliefs and/or the consequences of his actions and therefore he could not refuse the treatment himself, and he ordered the chemo be given. Of course, all this competency (and I'm not sure we are even using that word correctly, but whatever) testing and determination takes forever and a day so it really isn't applicable in emergent situations.
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Ah yeah, I guess I shouldn't say they're always treated exactly as children, only usually. Hopefully considering actual mental status instead of age is a trend that continues, though.

Eurekaa said:
What if the patient was a Jehovah's Witness?

If I am confident that the child displays a reasonable adult's level of competency and refuses treatment, I would follow their wish. Religious beliefs can transcend scientific reasoning, and often provide a deeper meaning to life than one who only follows science can understand. I would not have the child live by violating a serious belief and all the consequences that may result.
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I actually think that religious belief is totally invalid, but regardless if we're talking about somebody who is mentally competent to make decisions it is their life, not mine.
 
Last edited:
This has been asked many time on SDN. The decision/consensus has been, regardless of parental request or religious affiliation, if the child is in emergency care to transfuse and deal with legalities later.
 
Bacchus said:
This has been asked many time on SDN. The decision/consensus has been, regardless of parental request or religious affiliation, if the child is in emergency care to transfuse and deal with legalities later.
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This. Children have posed significant problems in law and medical ethics, especially children at an age where we begin to think that they are more capable of making their own decisions. Some ethicists have proposed a "Rule of 7's" approach for categorizing the ability to assent and consent to treatment, but this isn't a consensus opinion by any stretch. There are laws in many jurisdictions that offer protections to some populations (like Christian Scientists), but they would seem to conflict directly with laws motivated by parens patriae and the harm principle. Generally speaking, parents can choose to be martyrs, but they can't make martyrs of their children.

This is also why I focus on issues in psychiatry and medicine, rather than adolescents. 😉
 
sindadel said:
Here, we would be required to report to Child Protective Services and the matter would go to a judge.
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👍 This, if treatment can wait.

If it's a life or death emergency, the physician should give the transfusion. Even if he/she gets sued, what judge in their right mind would rule in favor of the parents?
 
Quix said:
This. Children have posed significant problems in law and medical ethics, especially children at an age where we begin to think that they are more capable of making their own decisions. Some ethicists have proposed a "Rule of 7's" approach for categorizing the ability to assent and consent to treatment, but this isn't a consensus opinion by any stretch. There are laws in many jurisdictions that offer protections to some populations (like Christian Scientists), but they would seem to conflict directly with laws motivated by parens patriae and the harm principle. Generally speaking, parents can choose to be martyrs, but they can't make martyrs of their children.

This is also why I focus on issues in psychiatry and medicine, rather than adolescents. 😉
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Why use age standards at all though? Is it not feasible to take it on a more case-by-case basis? Ageism in general strikes me as unethical, though. I guess I am still struck by the sheer variability in maturity and intelligence of adolescents.
 
LiveUninhibited said:
Why use age standards at all though? Is it not feasible to take it on a more case-by-case basis? Ageism in general strikes me as unethical, though. I guess I am still struck by the sheer variability in maturity and intelligence of adolescents.
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While there is variability between children, the average 7 year-old does not have the same intellectual resources as the average 14 year-old, which makes it reasonable to argue that there ought to be different approaches and standards for teenagers than for young children. Again, bear in mind that this is not a consensus opinion, nor is a child/adolescent's assent to treatment the same as legal consent to treatment.
 
Quix said:
While there is variability between children, the average 7 year-old does not have the same intellectual resources as the average 14 year-old, which makes it reasonable to argue that there ought to be different approaches and standards for teenagers than for young children. Again, bear in mind that this is not a consensus opinion, nor is a child/adolescent's assent to treatment the same as legal consent to treatment.
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Of course, but doctors don't treat averages, they treat individual patients. My point would be more along the lines that there are 14-year-olds more mature than the average 21-year-old, and 21-year-olds less mature than the average 14-year-old. So every once in awhile you will find a 14-year-old who actually is more competent than the law allows acknowledgement of. Now, I wouldn't sacrifice a whole lot to ensure that somebody can allow themselves to die for their religion, so I'll have to go with the law and screw the ethics here.

However, I am unfamiliar with the assent versus consent distinction. Elaborate?
 
LiveUninhibited said:
Of course, but doctors don't treat averages, they treat individual patients.
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Which necessitates an overall sociolegal framework to guide the treatment decisions concerning these individual patients. Like what we do with adults and the PSDA.

LiveUninhibited said:
My point would be more along the lines that there are 14-year-olds more mature than the average 21-year-old, and 21-year-olds less mature than the average 14-year-old. So every once in awhile you will find a 14-year-old who actually is more competent than the law allows acknowledgement of.
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Right, but this is a statistical outlier and does not undermine the proposed framework. The existence of exceptions does not invalidate the need for a guiding principle; it just shows that we need to be sensitive to context and use individual cases to clarify overarching frameworks, in addition to using the overarching frameworks to guide individual cases. This is the idea of a reflective equilibrium, and it's pretty common in ethics.

LiveUninhibited said:
Now, I wouldn't sacrifice a whole lot to ensure that somebody can allow themselves to die for their religion, so I'll have to go with the law and screw the ethics here.

However, I am unfamiliar with the assent versus consent distinction. Elaborate?
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It's not terribly complicated - assent is simply going along with treatment, versus a full consent. A kid assents when he lets you take his temperature, for instance, but it would not make sense to say that he consents in a legally binding sense. His parent or legal guardian, however, could provide consent for the procedure.
 
Eurekaa said:
What if the patient was a Jehovah's Witness?

If I am confident that the child displays a reasonable adult's level of competency and refuses treatment, I would follow their wish. Religious beliefs can transcend scientific reasoning, and often provide a deeper meaning to life than one who only follows science can understand. I would not have the child live by violating a serious belief and all the consequences that may result.

If however, the child is unsure about their committment to the religion, I would assume that it is in their best interest to survive, and disregard what the parents feel about it. I will carry out my duty to preserve life and proceed with the transfusion.
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It's not proper to allow someone to die because of their religious fanaticism. If a child isn't forced to receive treatment, we legitimize disgusting and archaic practices.
 
Children have the potential to possess an adult level of critical thinking and understanding, I don't think you should let age be the only factor in your decision. What I was suggesting was that the child proved fully competent in his decision to refuse treatment. Would you not respect his autonomy and force treatment still?
 
Quix said:
Which necessitates an overall sociolegal framework to guide the treatment decisions concerning these individual patients. Like what we do with adults and the PSDA.

Right, but this is a statistical outlier and does not undermine the proposed framework. The existence of exceptions does not invalidate the need for a guiding principle; it just shows that we need to be sensitive to context and use individual cases to clarify overarching frameworks, in addition to using the overarching frameworks to guide individual cases. This is the idea of a reflective equilibrium, and it's pretty common in ethics.
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I did not say there should not be a framework/guiding principle, just that it should be based upon actual mental status, not age. The outliers do undermine the framework because it is possible to conceive of a framework that does not cause injustice in a minority of cases. If a 14-year-old really were as mentally competent as the average 18-year-old, which would happen more often than you might think, then not treating them as an adult for medical decision-making is wrong. We only consult parents because we assume they will keep an incompetent minor's best interests in mind, and when it is clear they are not, intentionally or unintentionally, they are overruled. But consulting parents when the minor is actually mentally competent is non-sensical like consulting a proxy before an elderly person has dementia.
 
Eurekaa said:
Children have the potential to possess an adult level of critical thinking and understanding, I don't think you should let age be the only factor in your decision. What I was suggesting was that the child proved fully competent in his decision to refuse treatment. Would you not respect his autonomy and force treatment still?
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Yes...if the law is applicable. Yes, regardless, if its an emergency situation and I didn't have time to assess the competency of the individual.
 
Eurekaa said:
Children have the potential to possess an adult level of critical thinking and understanding, I don't think you should let age be the only factor in your decision. What I was suggesting was that the child proved fully competent in his decision to refuse treatment. Would you not respect his autonomy and force treatment still?
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I think the state should force treatment if the individual is a kid. I don't think it should matter if the treatment is contrary to his/her indoctrinated beliefs. You gotta salvage the kid's life.
 
Instead of age being the issue, should the issue rest upon whether the situation is life or death? If the child doesn't receive the transfusion they die; then the child is going to get the transfusion against the parents will.
 
Bacchus said:
Yes...if the law is applicable. Yes, regardless, if its an emergency situation and I didn't have time to assess the competency of the individual.
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Is age relevant in an emergency situation either, though? Unless it's established beforehand that they are competent and do not want such treatment one would think you would deliver the standard of care regardless of age. If an adult is screaming at you not to treat them, and if you don't they will imminently die, and you know nothing except that they are an adult, how do you know whether that adult is competent at that moment or in general? You don't.
 
dudechiefboss said:
Instead of age being the issue, should the issue rest upon whether the situation is life or death? If the child doesn't receive the transfusion they die; then the child is going to get the transfusion against the parents will.
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Well, I read in a biomedical ethics book that overruling parents of children should only be done when the harm is likely and significant. I think the reason is that you don't want the intervention to do more harm than good to the family, traumatizing the kid/parents for no compelling reason.
 
LiveUninhibited said:
Well, I read in a biomedical ethics book that overruling parents of children should only be done when the harm is likely and significant. I think the reason is that you don't want the intervention to do more harm than good to the family, traumatizing the kid/parents for no compelling reason.
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If the decision constitutes gross negligence, then it can be overruled. Whether or not it is considered grossly negligent is, ideally, determined by a judge before hand. In emergency situations, this is discussed very briefly with on-call legal counsel and then acted upon.
 
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