Boldt v. Boldt: A Pediatric Ethics Perspective
University of Washington School of Medicine, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington, USA.The Journal of clinical ethics (Impact Factor: 0.47). 09/2009; 20(3):251-7.
On balance, the potential harms and benefits of circumcision in an older child or adolescent are sufficiently closely aligned that parents should be permitted to make decisions about circumcision on behalf of their children. To make a case for prohibition, medical harms would have to be of such likelihood and magnitude that no reasonable potential benefit (social, religious, cultural, or medical) could justify doing it to a child. However, I would suggest that the following additional principles should apply: (1) Informed permission from parents is essential. Only about half of the parents considering neonatal circumcision are given any substantive information about the procedure. That practice is not acceptable for a procedure that is not medically essential and carries some risk of harm. A fully informed consent is essential, and must include a balanced discussion of potential harms and benefits of the procedure to the child. Parents should be given accurate and impartial information and allowed to make an informed decision regarding what is in the best interest of the child. (2) Consent of both parents should be required when the procedure is not medically required. It should not be performed in the face of parental disagreement. (3) Absent a significant medical indication, circumcision should not be performed on older children and adolescents in the face of dissent or less than enthusiastic assent. (4) Circumcision should be performed competently and safely by adequately trained providers.29 This should include infection-control measures, a sterile environment for the procedure, and no mouth-penis contact. (5) Analgesia is safe and effective. Adequate analgesia and post-operative pain control must be provided. In the case of Jimmy Boldt, I would suggest that without some compelling medical reason for performing a circumcision, the procedure should not be performed in the absence of agreement between his parents. The fact that Jimmy's father had sole custody does not eliminate the mother's ethical right and obligation to look after the welfare of her son. While the mother may not have legal decision-making authority, that legal determination does not appear to be related either to a lack of interest in her son's welfare or an inability to carry out that role. Jimmy is her son, and she has an interest in seeing his welfare protected. Whether or not she has legal rights, I would be very reluctant to perform an elective procedure for cultural or religious reasons without the permission of both parents and the unambiguous assent of Jimmy himself. Neither appears to be present in the case as it presented to the courts.
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ABSTRACT: The Case During the preanesthetic discussion for resection of pulmonary metastases of osteosarcoma, the anesthesiologist advises the 14-year-old boy and his parents that a thoracic epidural catheter would be the best way to manage post-thoracotomy pain. The anesthesiologist initiates a discussion commensurate to the adolescent's age, experiences and cognitive ability. The patient immediately refuses the thoracic epidural stating, “I don't want a needle in my back while I'm awake.” Despite reassurance by the anesthesiologist and parents of adequate sedation and analgesia, the patient still refuses. The parents, frustrated, scared and wanting the best for their child still ask the anesthesiologist to insert the epidural. The child's role in medical decision-making The American Academy of Pediatrics Committee on Bioethics 1995 recommended integration of children into the informed consent process (Table 5.1), and this has been reaffirmed both nationally and internationally. Indeed, the ASA has incorporated the principle of pediatric assent into its Guidelines for the Ethical Practice of Anesthesiology (Section I.2): Anesthesiologists respect the right of every patient to self-determination [and] should include patients, including minors, in medical decision-making that is appropriate to their developmental capacity and the medical issues involved. Anesthesiologists should choose to involve children in medical decision-making with the ethical objective of enhancing the child's self-determination, while keeping the child engaged in their care. Anesthesiologists can use the patient's age as a first approximation of a patient's cognitive and emotional development. Children under the age of 7 generally do not have decision-making capacity.
Chapter: Surgical Guide to Circumcision[Show abstract] [Hide abstract]
ABSTRACT: Informed consent is more than a process; it is a gestalt that embraces the concept of the provider (physician or other practitioner) and the patient engaging in a two-way exchange of ideas to best determine a medical course of action. In pediatric cases, the parents are the decision-makers for their children and are presumed to have the best interest of the child in mind. The most important point to keep in mind is that patients (parents) come with preconceived expectations and often cultural considerations. It is important to be sensitive to these and at the same time present a well-balanced summary of the pros and cons of circumcision. To that “a well-crafted informed consent document outlining the procedure, goals of surgery, risks, benefits, and expected outcomes of the procedure allows an opportunity to confirm that the patient has understood and retained the information needed to reach a meaningful decision.”
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