Samenvatting McDougall en Notini
Overriding parents’ medical decisions for their children: a systematic review of normative
literature
This paper reviews the ethical literature on conflicts between health professionals and parents about
medical decision-making for children, focusing on circumstances in which parent’s decisions ought to
be overridden by health professionals.
The review identified 9 ethical frameworks outlining circumstances in which a health professional is
justified in overriding parents medical decision-making for children. Each framework was centred on
a different moral concept.
1. Harm principle
Diekema argues that best interests can be difficult to define, conceived differently by parents and
health professionals, and do not represent the standard applied in practice. He suggests that
harm is in fact the central moral concept. In the harm principle, a health professional is ethically
justified in seeking state intervention when the parent’s decision significantly increases the
likelihood of serious harm as compared to other options. The harm principle is put forward
specifically in the context of conflicts about parents refusals of treatment. Diekema proposes 8
conditions that must all be met before considering the use of state intervention to require
medical treatment of children over parental objections:
- The refusal puts the child at ‘significant risk of serious 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’ than that associated with the parents’ preferred option.
- No other option would prevent serious harm to the child in a way that is more acceptable to the
parents.
- The state would intervene in ‘all other similar situations’, regardless of the nature of the
parents’ reasons.
- Most parents would agree that the state intervention was reasonable.
2. Constrained parental autonomy
This framework centres around the concept of a child’s basic needs. Ross argues that parents
should have a presumptive right to non-interference, a right that is restricted only if they fail to
provide for their child’s basic needs. She argues for the inadequacy of the best interests standard
as a guidance principle on the basis that families have group goals, distinct from the self-
regarding goals and interests of each member. And that parents may compromise the interests
of the child, provided that they do not sacrifice the child’s basic needs. She endorses 3 specific
criteria that need to be fulfilled in order for state intervention to be justified:
- Medical experts agree that the treatment is non-experimental and appropriate for the child.
- Denial of that treatment would result in the deprivation of the child’s basic needs.
- The anticipated result of treatment gives the child a change for normal healthy growth or a life
worth living as evaluated from the child’s perspective.
3. Best interests
Acting in an individual’s best interest is acting so as to promote maximally the good of the
individual. Kopelman, Buchanan and Brock’s state that the best interests principle is to serve only
as a regulative ideal, not as a strict and literal requirement and that a mere failure on the part of
the parents to optimise the child’s interest is not sufficient to trigger justified intervention,
parents are entitled to take into account their own self-interests and their obligation to their
Overriding parents’ medical decisions for their children: a systematic review of normative
literature
This paper reviews the ethical literature on conflicts between health professionals and parents about
medical decision-making for children, focusing on circumstances in which parent’s decisions ought to
be overridden by health professionals.
The review identified 9 ethical frameworks outlining circumstances in which a health professional is
justified in overriding parents medical decision-making for children. Each framework was centred on
a different moral concept.
1. Harm principle
Diekema argues that best interests can be difficult to define, conceived differently by parents and
health professionals, and do not represent the standard applied in practice. He suggests that
harm is in fact the central moral concept. In the harm principle, a health professional is ethically
justified in seeking state intervention when the parent’s decision significantly increases the
likelihood of serious harm as compared to other options. The harm principle is put forward
specifically in the context of conflicts about parents refusals of treatment. Diekema proposes 8
conditions that must all be met before considering the use of state intervention to require
medical treatment of children over parental objections:
- The refusal puts the child at ‘significant risk of serious 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’ than that associated with the parents’ preferred option.
- No other option would prevent serious harm to the child in a way that is more acceptable to the
parents.
- The state would intervene in ‘all other similar situations’, regardless of the nature of the
parents’ reasons.
- Most parents would agree that the state intervention was reasonable.
2. Constrained parental autonomy
This framework centres around the concept of a child’s basic needs. Ross argues that parents
should have a presumptive right to non-interference, a right that is restricted only if they fail to
provide for their child’s basic needs. She argues for the inadequacy of the best interests standard
as a guidance principle on the basis that families have group goals, distinct from the self-
regarding goals and interests of each member. And that parents may compromise the interests
of the child, provided that they do not sacrifice the child’s basic needs. She endorses 3 specific
criteria that need to be fulfilled in order for state intervention to be justified:
- Medical experts agree that the treatment is non-experimental and appropriate for the child.
- Denial of that treatment would result in the deprivation of the child’s basic needs.
- The anticipated result of treatment gives the child a change for normal healthy growth or a life
worth living as evaluated from the child’s perspective.
3. Best interests
Acting in an individual’s best interest is acting so as to promote maximally the good of the
individual. Kopelman, Buchanan and Brock’s state that the best interests principle is to serve only
as a regulative ideal, not as a strict and literal requirement and that a mere failure on the part of
the parents to optimise the child’s interest is not sufficient to trigger justified intervention,
parents are entitled to take into account their own self-interests and their obligation to their
