Pediatricians told child assent is an important, moral obligation

Doctors should always ask for a child's consent before treating them, and they should apologise when they proceed against the child's objections, argues a new commentary aimed at pediatricians.

This ethical debate itself is not new, the authors acknowledge in the journal Pediatrics, where they make a case for strengthening guidelines on pediatric assent.

"In our work, we noticed that there are lots of patients who lack the capacity to make decisions for themselves but who nonetheless have strong preferences about how they want to be treated," said lead author Jason Wasserman of Oakland University in Rochester, Michigan.

"They don't necessarily understand fully, or reason well, about their care, but they still often have firm preferences about what they want," he told Reuters Health by email.

"This doesn't mean we always give kids what they want; sometimes we are morally obligated to treat them over their objections because it's in their best interest," Wasserman said. "But if we want to treat kids as persons, then we have to solicit and take seriously their preferences."

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Wasserman and colleagues cite a 1995 letter to the editor of the same journal written by pediatrician and ethicist William Bartholome, in response to a revised statement on pediatric assent from the American Academy of Pediatrics' (AAP) Committee on Bioethics.

Bartholome said the organisation's statement didn't show enough respect for children, and that doctors should always ask for permission and apologise when they act against their patients' wishes.

Wasserman and his co-authors take up that position and offer several suggestions to improve current guidelines.

In its latest statement on pediatric assent in 2016, the AAP said doctors are "obliged to act out of fundamental respect for other persons by virtue of their personal autonomy." The Committee on Bioethics emphasised that informed consent should be seen as an "essential part" of healthcare, both parental permission and child assent should be included, and patients should participate in decision-making as appropriate for their developmental phase.

Wasserman and colleagues say this doesn't go far enough.

Some pediatric ethics organisations say a child's assent shouldn't be solicited if treatment is inevitable, they note. Instead, pediatricians should ask kids about their preferences, even if they already know they ultimately can't grant them.

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"And even when treating those kids over their objections is ultimately the right thing to do, pediatricians should acknowledge that the child has experienced that treatment as a harm," Wasserman said.

He and his colleagues offer an example to illustrate the doctor's moral obligation to the child. In the scenario, a pediatrician sees a 4-year-old who needs to have an abscess removed.

When the child sees the needle for the local anesthetic, he begins to cry and flail, saying he doesn't want the shot. The doctor explains to him why the shot is needed and how it will help him, and just before the injection, says, "Sorry, buddy."

Apologies demonstrate respect and are meant to honour a patient's objection, the commentary authors write. At the same time, apologies are not a concession of moral failure or expression of guilt.

"I appreciate the authors' concern for ensuring the children's voices be heard in their healthcare. At the same time, I do not think their position is that different from the AAP's position," said Bob Macauley, chairperson of the AAP Committee on Bioethics.

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"The one point of divergence is whether the child's agreement should be sought in situations where refusal cannot be honoured," he told Reuters Health by email. "The AAP believes that a choice is only a choice if it's really a choice."

The conversation should also include the parent, who plays a vital role in confirming assent and building trust between doctor and child. This is particularly true when the child is young or a newborn, said Margaret Moon, chief medical officer at Johns Hopkins Children's Center in Baltimore, Maryland. Moon served on the 2015-2016 AAP Committee on Bioethics.

"Parents and pediatricians together should figure out what level of engagement is appropriate," she told Reuters Health by phone. "It requires close teamwork for each individual child and each individual treatment to ensure the child is as engaged as possible."