Case Discussion: Objections to Medical Care
Case Discussion: Religious, Cultural and Philosophical Objections to Medical Care
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.
This patient, a 4-year-old, has sustained a wound that you would consider dirty and at risk of tetanus. What do you think is best for this child?
Focus here on the need for tetanus vaccine and immunoglobulin. Can also discuss whether the group feels antibiotics are indicated.
Most of you agree it would be best for the child to be vaccinated against tetanus, which in this case would involve both the vaccine and immunoglobulin. You would also be more comfortable if the child were on antibiotics. The mother has declined any of those treatments because of her naturopathic beliefs. Are you going to allow her to make that decision?
Emphasize that this is a different question than the one that preceded it. Simply having established what you think is best for the patient does not answer the question of whether a parent who disagrees with you can be overridden. The first question is about what you think is best for the child. The second question is about what authority you have to interfere with the choice of a parent.
What is your authority in this situation?
Except in emergency situations where a child's life is threatened imminently, or a delay would result in significant suffering or risk to the child, the physician cannot do something to a child without the permission of the child's parent or guardian. Touching (or administering a medication or vaccine) without consent is considered a battery under the law.
Given that, and assuming you have not been successful in changing the mother's mind, what are your options?
Only the "state" can order a parent to comply with medical recommendations. The physician's options include either tolerating the parent's decision (while continuing to try to convince them to act otherwise) or involving a state agency. This can take different forms, but most frequently includes either involvement of Child Protective Services (i.e., reporting medical neglect) or a court order. Both of these are a big deal and will generally be perceived as very adversarial by parents.
How do we decide whether a parent has exceeded her authority in making a medical decision for her child? What are the limits of parental authority to refuse a medical intervention? In other words, what is the threshold for when we should involve state agencies in a case like this?
When a parent places a child at significantrisk of seriousharm.
How much risk is too much for a parent to subject a child to? Does it matter how great the potential harm is?
Harm must be more than trivial. Generally, harm must be serious.
Does it matter how likely the harm is?
Risk of harm must be significant, not simply a possibility. The threshold in this case is lower if this is a grossly contaminated wound as opposed to a cut with a clean kitchen knife.
Does it matter how imminent the harm is?
In this case, the harm is not imminent in the sense that it will occur immediately. But there is a time beyond which the vaccine's effectiveness in preventing tetanus begins to drop. Thus, in this case, we have a day or two to try to work with this family, but not much more than that.
Does it matter whether the recommended treatment is accompanied by the potential for significant toxicity or side effects or risks?
Another thing that matters is whether benefit has been established. There is a difference between proven efficacy (data-based) and convention ("it's standard of care").
The usual ethical concepts of harm, benefit and best interests are value-laden. What seems to be obviously a minimal harm to many medical professionals may seem like a huge harm to those with different belief systems. What counts as significant is very personal.
Judgments in medicine about efficacious care are often based on minimal data and can change with time. It takes a degree of arrogance to overpower parents' assessment of what would be best for their child.
Would it matter if the parents were Christian Scientists and refusing immunization, immunoglobulin and antibiotics because of their religious belief (in contrast to a nonreligious belief like naturopathy)?
The constitution requires that government not interfere with religious practice or endorse particular religions.
The government has an interest in protecting children and innocent third parties.
Freedom of religion does not permit a child to be harmed, neglected or abused through religious practices. In Prince v. Williams, the United States Supreme Court stated, "Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves."
The American Academy of Pediatrics (AAP) does not believe refusal of routine immunizations should be viewed as child neglect.
Are there other important considerations?
Conditions for justified state interference with parental decision-making:
- By refusing to consent are the parents placing their child at significant risk of serious harm?
- Is the harm imminent, requiring immediate action to prevent it?
- Is the intervention that has been refused necessary to prevent the serious harm?
- Is the intervention that has been refused of proven efficacy and therefore likely to prevent the harm?
- Does the intervention that has been refused by the parents not place the child at significant risk of serious harm, and does its projected benefits outweigh its projected burdens significantly more favorably than the option chosen by the parents?
- Would any other option prevent serious harm to the child in a way that is less intrusive to parental autonomy and more acceptable to the parents?
- Can the state intervention be generalized to all other similar situations?
- Would most parents agree that the state intervention was reasonable?
Conclusion with Suggestions
Respect and care must remain the atmosphere in disagreements with parents.
Interference with parental decision is not appropriate if the prognosis is grave even with treatment.
Religious, Cultural and Philosophical Objections to Medical Care
This instructor's guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's.
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