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Pediatricians should remember that the child, not the parent, is the patient and that their professional, ethical, and legal obligations are to the child. While parents in our society have been given wide latitude to raise children as they see fit, there are limits at which the state can appropriately intervene: While parents may spank their children, child abuse is not permitted. While parents may choose a variety of educational resources for their children—from home schooling to a variety of religious schools to private and public schools—the state does demand, at least in theory, that children achieve some level of literacy. Pediatricians, therefore, care for children and work with their parents in a social context that requires their intervention in ways that may range from working with parents to make sure they understand a medically complex situation to notifying the state of neglect or abuse.1 This chapter focuses on three areas of complexity in which the law, ethics, and clinical judgment intertwine: (1) Who makes decisions when it comes to caring for children and adolescents? (2) Who is able to refuse treatment—the child and/or the parent for the child? and (3) When is confidentiality an issue for an older child or adolescent?


The United States has become a nation of diverse cultures; thus, sensitivity toward and understanding of child-raising practices from other parts of the world are increasingly important. While some practices may seem abusive in the context of American cultural values, physicians should realize that the intent behind the practices is almost always benevolent and not abusive. Explanations and education, not legal interventions, may be the solution to the problem.2 Physicians who care for children should always remember that the ethical concept of “respect for persons” does not have a minimum age. While demonstrating respect for a 16 year old may be quite different from demonstrating respect for a 6 year old, which is different from the respect due an infant, the principle is the same at any age.3


While parents, of course, make decisions about their children’s health care and all other aspects of the children’s lives, one of the more dramatic developments in US legal history within the last 50 years has been courts’ recognition of the rights of adolescents to make decisions for themselves—about health care and in a variety of other contexts.4 Before the 20th century, children (until recently, all those under 21) were considered chattels of their fathers, and appropriate and beneficial treatment of a child without the father’s permission was considered a wrong to him and his right to control his child. Thus, the father (not the mother) could sue the physician for treating his child correctly but without his permission. Before child labor laws removed children from their jobs in factories, fathers had the right to the entirety of their children’s salaries. Child abuse was not a crime in the United States in 1900, and mandatory reporting of abuse ...

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