++
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 ...