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  • Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95: 314-317.
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A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success.

Can you treat this child without parental permission?

Case Discussion

Your first duty is to the health and welfare of the child. Having attempted unsuccessfully to reach her parents for consent, you should proceed with x-rays and treatment of her fractured forearm. Rapid treatment of the child's pain and fracture are clearly in her best interest. When optimal treatment requires immediate intervention, treatment should not be delayed even if consent has not been obtained.

An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful.

What are your obligations in this case? How should you proceed?

Case Discussion

A lumbar puncture is the only way to diagnose meningitis and a delay in treatment could cause significant harm to the child. Complications from the procedure are very rare, and the benefit in this case is likely to be substantial. There is not time to obtain an ethics consult or court order. The physician should attempt to address the parents' misconceptions about lumbar punctures and to reassure them about the safety of the procedure and perhaps offer to use appropriate pain control methods. A second opinion from another physician may prove helpful.

Should these efforts not result in parental permission, the physician is justified in contacting the state’s child protection agency to obtain the authorization necessary to proceed with the procedure and treatment of the child. While parental authority to make medical decisions for their children is broad, it does not include choices that may seriously harm their children. As long as the physician has used reasonable clinical judgment in determining the need for the lumbar puncture, legal liability should be minimal.

A 5-year-old child has just had his second generalized tonic-clonic seizure in a 4-month period. You have recommended starting an anticonvulsant. The child’s parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures.

How should you respond to the parents’ request?

Case Discussion

The parents have the authority to make a choice of this nature. In general, courts have been reluctant to overrule parental wishes in most situations where that decision does not place the child at considerable risk. Though failure to start an anticonvulsant may increase the risk of further seizures, this does not pose a substantial enough risk to the child to justify overriding the parents' wishes, especially given the potential risks and side effects associated with the medication. Though you may not agree with their decision, the decision is a reasonable one that does not place their child at substantial risk of increased harm.