Uneasy Alliance: Pediatric Shared Decision-Making and Maltreatment

Abstract

Effective medical pediatric decision-making (PDM) relies on a therapeutic alliance between minor patient, guardian(s), and provider(s). Legal and social precedent support broad parental discretion in the absence of immediate and severe endangerment of the minor’s welfare. However, in many cases of maltreatment, suspected or substantiated, parents retain PDM rights. Additionally, most minor protection statutes and processes aim for familial (re)unification where possible. Together, they create a unique ethical conundrum. The possibility of a guardian who is both surrogate and cause of harm threatens the conventional decision-making model, and providers may struggle to navigate this uneasy alliance. This paper offers an analysis of the primary challenges to PDM in such circumstances and shows that many of the ethical questions arise as the decision-making process unfolds and information is gathered. In doing so, it makes the argument that too much of a focus on individual components like thresholds for harm or determination of intent may be counterproductive. Finally, it offers suggestions to guide healthcare professionals and institutions, emphasizing as the primary goal the preservation of the therapeutic alliance which assures the minor’s well-being through processes that support each of its members.

https://pediatricethicscope.org/article/uneasy-alliance/