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Medical Ethics for Children: Applying the Four Principles to Paediatrics

Author(s): P. Baines

Source: Journal of Medical Ethics , Mar., 2008, Vol. 34, No. 3 (Mar., 2008), pp. 141-145

Published by: BMJ

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Clinical ethics

Medical ethics for children: applying the four principles to paediatrics P Baines

Correspondence to: Dr P Baines, Paediatric Intensive Care Unit, Royal Liverpool Children's Hospital, Eaton Rd, Liverpool L12 2AP, UK; pbb@liv. ac.uk

Received 21 July 2006 Revised 20 November 2006

Accepted 21 November 2006

ABSTRACT I will argue that there are difficulties with the application

of the four principles approach to incompetent children.

The most important principle - respect for autonomy - is not directly applicable to incompetent children and the most appropriate modification of the principle for them is

not clear. The principle of beneficence - that one should act in the child's interests - is complicated by difficulties in assessing what a child's interests are and to which standard of interests those choosing for children should be held. A further problem with the four principles

approach is that parental authority does not follow clearly

from the four principles.

In recent years parents and medical teams treating ill children have been increasingly unable to agree on medical treatment. This has been demonstrated

by a mounting number of cases where the courts have been asked to decide a child's medical care. This paper considers the application of the dominant approach within Western medical ethics - the four principles approach - to children. The four principles are respect for autonomy, benefi cence, non-maleficence and justice.

The four principles approach was developed by Beauchamp and Childress and has achieved promi nence, at least partly, as a result of their authoritative book which is almost the bible of medical ethics.1 Perhaps another reason why the four principles approach is dominant is the straight-forwardness of it. The four principles are akin to rules to be applied in each situation, which may appeal to doctors and nurses brought up in the scientific tradition. The principles are perhaps regarded in the same way as the facts of evidence based medicine and are more attractive to the scientifically trained mind than are the more vague recommendations of other ethical approaches. As an example, consider the requirements of a virtue ethics approach: "the virtuous person perceives a situation, judges what is right and wants to act accordingly because it is in her disposition to act

well."2 The four principles are more direct, concrete and action-guiding than is, for example, a virtue ethics approach.

One of the standard cases of medical ethics is the

child of Jehovah's Witness parents, urgently need ing a blood transfusion following a road accident.3

This case is used as one of four paradigm cases that Gillon uses in a festschrift edition of the Journal of

Medical Ethics (October 2003) devoted to methods, to argue that the four principles approach is the best way to analyse and resolve ethical problems in medicine.

".. .Ranaan Gillon analyses this case using what he has described as the 'four principles plus scope approach7, concluding that the surgeon, if he cannot obtain parental consent to save the child's life is morally right (and probably legally right) to override their refusal and administer a blood transfusion on the grounds (briefly summarised) that the child does not fall within the scope of the principle of respect for autonomy and that the parents' authority to decide on medical treatment for their child

should not and legally does not extend to imposing severe and probably fatal harm on their child in pursuit of their own religious beliefs, rather than in what their society, though not their religion, regards as the child's best interests".3

I do not disagree with Ranaan Gillon's proposed course of action. What I intend to do is to examine

how the four principles approach works for children.

Criticisms are made of the four principles approach.4-6 I will concentrate on its application to children, which is important for two reasons. Firstly, as children comprise up to one fifth of the population, if the approach does not apply to children, then claims for its importance are under mined.7 Secondly, as the medical care of children is often based on the care of adults (though paediatricians have long emphasised the important differences which separate children from adults) it is likely that the four principles will be applied to children. Is this appropriate? I will argue that there are particular difficulties with the application of the four principles approach to incompetent children, though the approach may be applied to competent children as it would to adults.

AUTONOMY Respect for autonomy is often claimed as the most important of the four principles and it has been described as "...the first among equals".8 An individual's freely chosen course of action should not be thwarted just because it would be better for that person if he acted in a different way. Others

may, of course, intervene if the chosen course of action was to harm them. There are several ways to justify the importance of respect for autonomy, perhaps the strongest is the claim that because there is no one ideal way to live a life, there is no objective standard to guide us, we must all make our own choices based on the things which are important to each of us as individuals.

Important developments in recent years in Western medical ethics have concentrated on

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Clinical ethics

autonomy and the way in which autonomous choices may (or should) override the other principles, such as beneficence or non-maleficence which perhaps in the past have been allowed to take precedence over a person's autonomous choice ("the Doctor knows best"). It is now widely accepted (at least in the UK and the USA) that a competent person's decision should be accepted (even though others believe that the person's choice is wrong). Autonomy is a complex notion having developed from several

sources, amongst them both political philosophy and moral philosophy. Dworkin provides a clear discussion of some of the complexities of autonomy,9 though I do not intend to consider it in detail. I will argue that some children are not autonomous and so the principle of respect for autonomy must at least be modified before it is applied to them.

The abilities that are involved in a person being competent to make autonomous decisions have been described.10-12 These

abilities are obviously lacking in some children. For example, if a newly-born child needs a surgical operation there is no sense in which the child can make a meaningful choice to have one operation or another, or indeed between an operation and no treatment. They lack the ability to communicate and under stand: someone else must choose. This is the larger group of children who are not autonomous. A second, but more troubling group who lack autonomy are older children. The abilities of some older children to absorb information, to rationalise and communicate are perhaps the equal of an adult's, but their decisions are often overruled. What they may lack is the integrity of being a particular person persisting over time, choosing their actions accepting and reflecting on the consequences of their actions: living as an autonomous person. Dworkin describes that autonomy is "...a whole way of living one's life and can only be assessed over extended portions of a person's life."13 My claim is that a child's judgement may be overruled by others, not because they lack the ability to understand the information available to them or to reason correctly, but because others (their parents or perhaps the courts) believe that they have made an incorrect assessment of the consequences for themselves. Perhaps a child will allocate too much importance to short term advantages instead of the longer term. I have described this group as more troubling because we allow adults to choose unwisely, but we prevent children from making decisions that seem unwise to others. We allow adults to accept the consequences of choosing in a way that seems unwise to others (as an example, we allow adults to smoke), but we protect children from the consequences of unwise decisions both by legislation (which prevents children under the age of 16 from purchasing cigarettes) and by entrusting them to the care of their parents who will prevent them from choosing unwisely until they are mature. This group of older children is more troubling because the features which separate these rational, able children who are not permitted to choose unwisely (in the eyes of others) from adults who are permitted to choose unwisely are hard to pin down, and if we were to pin them down it would be difficult to set a clear threshold to separate incompetent children from competent adults.

We tend to treat children as if they were not autonomous: decisions are made for them by adults, usually their parents, but also by others with responsibility for them, including teachers or other relatives. The decisions of non-autonomous children may be overruled by adults in a way that we would not overrule decisions made by adults.

However, as the Gillick ruling recognised, there is a group of children (aged<16 years) who have the appropriate abilities to make autonomous decisions. Once children are able to make autonomous decisions then they are no longer children - they are effectively adults, and (as with adults) to overrule their autonomous decisions must be wrong for the same reasons that it would be for adults. I do not intend to consider this group of autonomous children. The four principles approach may be applied to them in the same way that it would be applied to adults (though there may be disagreements about who should be competent to choose autonomously). But some children are not autonomous (though this is not the only aspect that separates children from adults). A lack of autonomy is an important part of being a child: we accept that because they are children they may choose unwisely (about where to cross the road, or what to eat, or whether to go to school). Others, usually their parents, may override the choices that a child has made. In this paper I am interested as to how we can apply the four principles approach to unarguably incompetent children.

APPLICATION OF RESPECT FOR AUTONOMY TO CHILDREN If I am correct to argue that some children are not autonomous, then the principle of respect for autonomy is not directly applicable to them. How may the principle of respect for autonomy be applied to them?

Firstly, some - child libertarians - would claim that the four principles approach may be applied directly to children. Children should be able to make their own decisions and should not be protected by 'paternalistic7 parents.14 On one level this is nonsense. The suggestion that an infant (under one year of age) needing treatment would be able to understand the options available, including the consequences of no treatment, and then express a choice could not be taken seriously. The claim that children of this age have a 'right7 to self determina tion or that we should respect their autonomy is not tenable.

However, the important point made by the child liberationists is that the age at which competence, or decision-making capacity, is granted to children is too late. As an example, there is a sad case

where a teenage child (of Jehovah's Witness parents) with cancer was obliged by court intervention to receive blood products against his express wishes. As an adult, his need for blood products continued and at this time his rejection of transfusion

was accepted and he died.15 This highlights the fact that although there may be important decisions about which children should be recognised to be competent, we'd have to accept that there are some children who obviously lack any ability to choose or choose in any meaningful sense.

How can we apply the principle of respect for autonomy to children who are not autonomous? There are two responses to this question. Firstly, if respect for autonomy is not appropriate in children, then perhaps it just drops out of sight leaving beneficence, non-maleficence and justice. This bears some resemblance to the Children Act "...the child's welfare shall

be the court's paramount consideration...".16 Acting in a child's welfare must be similar to acting on the basis of the combined principles of beneficence and non-maleficence.

But to exclude autonomy altogether may not be right. Children do not suddenly, overnight, develop the abilities which are needed for a person to act autonomously. A child's ability to act autonomously will mature if the child is encouraged to develop the abilities which underlie her competence to make autonomous decisions. Perhaps a child should be encouraged to take responsibility, at first in areas where the consequences of choosing unwisely are less severe or are short term rather than

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Clinical ethics

longer term. In this way the child will be able to develop, learning to take responsibility as an adult. An approach where a child is allowed no responsibility at all until majority seems less likely to be successful in developing the skills needed to act autonomously.

Recognising this, a second way to modify the four principles approach is to alter the principle of respect for autonomy to a principle that we should protect the developing autonomy or perhaps respect the future autonomy of the child. This approach recognises that development of autonomy should be encouraged in children. What it would mean to change the principle of respect for

autonomy to one that requires we protect the child's future autonomy is less clear. As an example, perhaps a child is an outstanding athlete. Should she be allowed to miss some lessons to concentrate on athletics? On one interpretation of a principle to protect the child's future autonomy (or right to an open future), the child should attend school so that she will have both scholastic achievements and sporting achievements. Then, at a later age she (the adult the child has become) can choose

which of the paths to concentrate on. But if she is obliged to attend school perhaps she will not fulfil her potential as an athlete. She will be a mediocre athlete and (perhaps) a mediocre student. Although in one sense her future autonomy is protected: she can decide what she wants to do at some stage in the future. In another sense it has not: the option of being a

world class athlete has been removed. In this example, what it means to protect or respect a child's future autonomy is not clear. Parents who had chosen either course could be equally praised (or blamed). Feinberg has considered this paradox: the way that the child is treated will determine the interests of the adult that the child will become.17

Whether an approach that required development of a child's autonomy for the future would produce a different outcome from acting in the child's interests is not clear. I believe that to protect a child's autonomy must be in a child's interest, and this must be true if we regard respect for autonomy as being fundamental not only within medical ethics but also more generally within a liberal society.

One approach that I will argue is wrong is to transfer the strength of the claims of the principle of respect for autonomy to the parent. This is the idea expressed in the claim that the parent must make decisions for a child. One way in which this may be expressed is the claim that a doctor or nurse is being paternalistic in seeking to persuade a parent to another course of action. The glib response is to point out that someone must be paternalistic towards children. The idea here is that although parents do have authority over their children (and it would be difficult to discharge parental duties without authority) this authority does not have the same moral force as respect for autonomy. Parental authority over children is justified on a different basis from respect for autonomy. The basis of parental authority will be considered below. In support of this, the English courts have consistently overridden decisions made by parents where these decisions are not in the best interests of children,18-20 though they have consistently supported decisions

made by competent adults when others have argued that this is not in the best interests of the adult concerned.21

I have argued that the principle of respect for autonomy may not be applied directly to incompetent children. The four principles may be applied to older, competent, children in the same way that they are applied to adults. The way in which the principle of respect for autonomy may be modified for incompetent children is not clear.

APPLICATION OF THE PRINCIPLE OF BENEFICENCE TO CHILDREN I will consider two difficulties with beneficence. Firstly how we are to assess what is in another's interests is not clear and secondly, the standard to which those choosing for others should be held needs to be examined.

The foremost problem when choosing for others is that there is no universal agreement about what a good life is. Many philosophers and others have attempted to develop objective theories of well-being, but there is no clear agreement. Competent adults make their own judgements as to what they think will make their life go well, but incompetent children are not able to make these choices. Importantly, the way that we assess a person's interests (when they are not able to choose for themselves) will alter the medical decisions that are made. For example, de Grazia has discussed the way that different value theories (different theoretical approaches to assessing a person's interests) may alter the decisions which are made about treatments. He considered three approaches (mental state theories, desire theories and objective lists) arguing that the different theories alter medical decisions that would be made for

disabled newborn babies or those in a persistent vegetative state.22 As has already been described, a child's decisions may be overruled in a way that an adult's decision may not. In some cases there may be agreement about another's interests (perhaps the disagreement is about the best way to achieve what others

would agree is in the child's interests). But in at least some cases, there is disagreement about what another's interests are, and until there is clear agreement on the aim or end or ultimate good of life, then there will not be a clear, objective, way to agree another's interests when they cannot judge for them selves.

The second problem with beneficence is the standard to which decisions should be made. When others (the child's parents or medical team) choose for children, they usually aim to act in the child's best interests as if this is an objective

measure, but what we mean must be spelt out. It does not mean the best that is possible for a child. For example, we would not suggest that children born to poor parents should be adopted by more affluent potential parents. Secondly, a best interests standard does not recognise the complex way that interests must be balanced within a family. For example, for the parents who have two or more children, the interests of their other children must be considered and it is unlikely to be possible to act in the best interests of all of their children. Furthermore, even if this were possible, a best interests standard allows the parents no time or space to consider their own interests and so is very demanding. To hold the child's parents (or medical team) to a best interests standard is undesirable given the other, competing, claims for them. If we retreat from a best interests standard then what standard should we use?

A possible standard is that decisions should be in a child's interests. However, where parents have more than one child they may reasonably act against the interests of one of their children (albeit to a limited extent) for advantages to their other children or to themselves. A trivial example would be a parent

who put both of their two children in a car to take one to a swimming lesson. The child attending the swimming lesson benefits, but a car trip for no good reason is not in the interests of the other child.

Another example of the way in which parents may act in a way that is not in a child's interests is in refusing vaccination. When the English courts were asked to consider whether the children of separated parents should be vaccinated, the trial

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Clinical ethics

judge noted "The court's decision is that on the medical evidence...immunisation is in the children's best interests"23

and yet also noted that "I accept a parent's right to choose whether they accept medical advice to have immunisation or not".24 In recognising that vaccination is in a child's interests and yet parents are free to choose whether a child should be vaccinated or not, the parents are not held to a standard that they should act in the child's interests. One response to this is to recognise that medical interests are only one component of the child's overall interests "...the judge had to have regard to all relevant factors and not just the assessment of medical risks and benefits."25 So although vaccination is in a child's medical interests, this is only one component of the total or overall interests of the child. The child's overall interests may be better

met by remaining unvaccinated. However, if we accept that vaccination is in a child's medical interests, the non-medical advantages which accrue from not being vaccinated and which would outweigh the effectiveness of vaccination in reducing death and serious disease are not clear. The court considered the

case only because the separated parents were in dispute, otherwise the choice would have been made by the parents. It seems that parents are allowed the authority to act in a way that need not be in their child's interests.

If the second standard is too demanding, then perhaps the standard should be that choices made for children should not be

against their interests (which seems an undemanding standard). However even this standard may not be met in practice. Consider the child of parent's who smoke. Parental smoking is against the child's interests on a variety of levels and causes a significant risk of harm up to and including death. For example, the excess number of deaths and hospital admissions as a consequence of parental smoking were calculated for the United States during the 1980s: smoking caused an annual excess number of 2000 deaths from sudden infant death syndrome and 14 deaths from asthma.26 However, it seems too draconian to require that children should be separated from parents who smoke. One response may be that parental smoking is against a child's medical interests, but as medical interests are only one component of the child's overall interests, the child's overall interests are better met by remaining

with (smoking) parents. However, given the severity of harm (up to death) and the frequency of the harms which result from parental smoking, it is not clear that these are less than the harms (to the child) of separation from the natural parents. However, in the assessment of interests, the interests of others within the family, as well as the child, must be considered. Perhaps the interests of the parents need to be added in when deciding how to act. So, in assessing the overall interests of the family, as well as the interests of the child, there are also the interests of the parents and other members of the family to be included. In assessment of the overall interests of the family (or perhaps the summed interests of the individuals within the family), it may be that it is the addition of the parent's interests in being a parent that are important in the child remaining with the natural (smoking) parents.

I am not sure what an appropriate standard should be. The most promising approach would be that of a reasonable interests standard and perhaps that would mean that acting against a child's interests would acceptable if the harms were limited and were justified by advantages to others in the family group. The details of this approach remain to be developed.

THE JUSTIFICATION FOR PARENTAL AUTHORITY

One problem with the four principles approach is that it does not clearly justify why parents should make medical decisions

for children. Ranaan Gillon states that "...the parents' authority...should not and legally does not extend to imposing severe and probably fatal harm on their child".3 What is the basis of the parental authority? The justification of parental authority must be robust if it can extend to imposing harm on a child. The way in which family and friends are unaccounted for in approaches which take respect for autonomy as a guiding principle has been considered in an important book.27 Parental authority is a particular example of this more general problem with medical ethics grounded in the principle of respect for autonomy.

There are two promising ways to base parental authority within the four principles. Firstly, that it is in the interests of the child (beneficence). Or secondly, based on respect for autonomy, but in this case it is respect for the parent's autonomy (individually or jointly) not the patient's (child's) autonomy.

Parental authority may be based on the child's interests. For example, parents may be best placed to make decisions regarding their child's care - perhaps because they know their child best, or because they will be responsible for implementing the care and will be more committed to plans they have chosen. In this case, the parental authority is based on the advantages to the child of parental authority. Parental authority does not exist for the parent. If a parent acts in a way that would disadvantage their child, then there is no longer any justification for the parent's authority. What this would mean is that if there was dispute over the best treatment for a child, the dispute would be resolved by deciding which of the treatments seemed to be best for the child (accepting all the difficulties with the assessment of a child's interests). If this is true, then parental authority does not extend to imposing lasting harm on a child. The only harms justified by this basis of parental authority would be short term harms offset by longer term benefits (an example would be the short term harms caused by an operation which are justified by the gains in health or longevity as a direct consequence of the operation). A parent could not appeal to the fact that they should make these decisions merely because they were the parent: if there was disagreement, the guiding principle would be the interests of the child. Although this seems a plausible justification, the way in which parents can act against their child's interests (discussed above) suggests that this justification is incorrect or incomplete. An alternative justification of parental authority is the

recognition that, for at least some people, a large part of that person's interests may be to have children and nurture them till maturity (and beyond). Children are important in a person's life. It is this aspect that is recognised within the human rights legislation in Article 8 as "Everyone has the right to respect for his private and family life, his home and his correspondence. There shall be no interference...".28

However, there is an asymmetry between the fact that being a parent is only one part of the parents' life, but parental decisions may affect (perhaps dramatically) all of a child's current (and future) well being. This means that the strength of the justification of parental authority on the basis that to intervene would be an infringement of the parent's autonomy is less strong than justifications of restrictions on parental autonomy to protect or encourage the child's development. Restricting a parent's autonomy will override only one aspect of a parent's life but acting to protect the child's future may enhance the development of the whole child.

Parental authority is not unlimited. In an analogy, some parents are husbands. A husband can make decisions about how

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Clinical ethics

they would like their relationship with their wife to be. Others would be wrong to intervene, but a wife is not under an obligation to go along with her husband's plans (and indeed a forcible insistence that she did would be an infringement of her autonomy). Children are not in the same position as spouses, but the analogy lies with the fact that neither children (nor spouses) are the sort of thing that another can make unrest ricted decisions about or for. The clear ability of spouses to reject choices made for them provides justification for concern if strong claims are made for parental autonomy. The analogy recognizes that there must be limits to parental autonomy in relation to children as there are to the autonomy of a spouse in relation to their partner. This justification of a parent's authority highlights the

tension between the enormous commitment needed to be a

good parent and the need to be impartial or disinterested to choose wisely based on an objective assessment of a child's interests. Good parenting demands sacrifice, dedication and commitment - the sleepless nights and unreasonable demands that children make on their parents can be met only through enormous devotion by the parents. But, if we accept that there is in some sense an objective or ideal conception of a child's interests, then, when decisions must be made in the child's interests, different options must be balanced, one against the other, impartially and dispassionately. When choosing in a child's interests, a parent must try to separate the love and commitment they have for their child (their interest in being a parent) from the interests of their child. Perhaps the dedication that is the prerequisite of good parenting stands in the way of

making an objectively correct medical decision. For example, parents' love and dedication for a child needing major surgery may prevent them allowing potentially life-saving surgery because they could not contemplate the pain or disfigurement that their child would suffer. Alternatively, perhaps a parent's inability to accept that their child's illness would inevitably be fatal would lead them to demand that painful treatment continue long after there was any prospect of cure (and inflict unpleasant or painful treatment for no advantage to the child). My claim here is that love and dedication are requirements of good parenting, and yet it is this very commitment to their child which disturb a parent's impartial assessment of their child's interests. If this is so, then parents are not best placed to make some decisions for their child.

I have argued that the four principles approach does not give a clear way to account for the commonplace fact that parents make medical decisions for their children.

CONCLUSIONS In summary, there are difficulties with the application of the four principles approach to incompetent children. Two of the principles (respect for autonomy and beneficence) must be modified, though the way that the principles should be modified is unclear. Parents make decisions for children. The

justification for this is not clear within the four principles approach.

Gillon issued a challenge in the festschrift edition of the Journal of Medical Ethics,29

"I think the four principles should also be thought of as the four moral nucleotides that constitute moral DNA - capable, alone or in combination, of explaining and justifying all the substantive and universalisable moral norms of health care

ethics and I suspect of ethics generally!...I have routinely asked audiences and readers...to offer disproof of the hypothesis by arguing either against the moral acceptability of any one of these four prima facie principles or by arguing for the need for additional normative and universalisable

moral principles that can't be explained by one or some combination of the four...Let me renew this Popperian request for disproof."

I have argued that the four principles approach may not be easily applied (if at all) to children. This is because both respect for autonomy and beneficence depend on the child being sufficiently mature to be competent. The four principles approach leads to the risk that respect for parental autonomy may overwhelm the child's interests. If I am correct in these criticisms, then we need to develop an approach to ethics for children, which will offer a way to deal with incompetent children.

Acknowledgements: I am indebted to Angus Dawson of Keele University for his constructive criticisms and I am grateful to the two reviewers from the Journal for many helpful and insightful comments.

Competing interests: None.

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