Case Summary

A 4-year-old child presents to the emergency department with a 3 cm laceration sustained while walking around in a friend's backyard. The wound is moderately dirty. The child's mother agrees to have the wound irrigated and sutured. She says she believes in naturopathy and will not permit antibiotics or immunizations. The child has had no tetanus immunizations.

  • Is this a decision that you will permit the mother to make?
  • How do we decide when it may be necessary to interfere with a parental decision?
  • If you decide that a parental decision places a child in danger, what are your options?
  • Under what conditions would you feel compelled to call Child Protective Services or obtain a court order to compel treatment?
  • Does it matter if the basis for the parental decision is religious, cultural or something else?

Learning Objectives

After participating in this module, the learner should be able to:

  1. Understand the components of informed consent or permission
  2. Understand the limitations of a parent's right to refuse treatment for a child
  3. Identify the steps one must take to justify involving state agencies to compel treatment of a child
  4. Recognize the conflict between the parent's values and those brought to the situation by medical professionals, and identify strategies for resolving this conflict

Suggested Reading for Students

Buchanan A, Brock D. Deciding for Others: The Ethics of Surrogate Decision-Making. New York, NY: Cambridge University Press; 1989.

Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;95 (2):314-317.

Committee on Bioethics, American Academy of Pediatrics. Religious exemptions from child abuse statutes. Pediatrics. 1988;81:169-171.

Committee on Bioethics, American Academy of Pediatrics. Religious objections to medical care. Pediatrics. 1997;99:279-281.

Diekema, DS. Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theoretical Medicine and Bioethics. 2004;25 (4): 243-64.

Flamm AL. Understanding faith: when religious parents decline conventional medical treatment for their children. Case Western Reserve Law Review. 1995;45:891.

Fost NC, Freeman JM, Seidel HM, Wilson MH, Oski FA. Could you handle this case in a bloodless way? Contemp Pediatr. 1990;April:127-137.

Fraser C. Suffering children and the Christian Science church. The Atlantic Monthly. 1995:105-120.

Holder A. "Circumstances Warranting Court-Ordered Medical Treatment of Minors." 24 POF 2d 1980: 169-210.

Relman AS. Christian Science and the care of children. The New England Journal of Medicine. 1983;309:1639.

Schoeman F. Parental discretion and children's rights: background and implications for medical decision-making. Journal of Medicine and Philosophy. 1985;10:45-61.

Swan R. Faith healing, Christian Science, and the medical care of children. The New England Journal of Medicine. 1983;309:1639-1641.

Vorys YV. The outer limits of parental autonomy: withholding medical treatment from children. Ohio State Law Journal. 1981;42:813-829.

This student's guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital.

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1. Instructor's Guide 2. Student's Guide 3. Case Discussion