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Instructor's Guide

Case summary

A 4-year-old child presents to the Emergency Department with a 3 cm laceration sustained while walking around in a friend’s backyard. The wound is moderately dirty. The child’s mother agrees to have the wound irrigated and sutured. She says she believes in naturopathy and will not permit antibiotics or immunizations. The child has had no tetanus immunizations.

  • Is this a decision that you will permit the mother to make?
  • How do we decide when it may be necessary to interfere with a parental decision?
  • If you decide that a parental decision places a child in danger, what are your options?
  • Under what conditions would you feel compelled to call Child Protective Services or obtain a court order to compel treatment?
  • Does it matter if the basis for the parental decision is religious, cultural or something else?

Alternative cases

  • Dennis Nixon and his wife, Lorie, belong to a small religious sect called the Faith Tabernacle Congregation. They believe that disease comes from the devil and that only God can cure illness. They believe in divine healing and do not seek medical care for their children when illness strikes. Instead, they spend much time in prayer and, for serious illnesses, may seek to be “anointed” at their church.

    The Nixon’s have 10 children and they take good care of them. Lori is pregnant with another. The children always wear helmets when riding their bicycles. In 1991, one of their children, an 8-year-old named Clayton, died of complications resulting from an ear infection treated with prayer alone. In June of 1995, their 16-year-old daughter, Shannon, began to experience dizziness, weakness, constant thirst and vomiting. She lost weight. After several weeks her mental status began to wax and wane. On June 21, amidst nearly constant prayers, she fell into a coma and died.

    A Pennsylvania prosecutor took the Nixons to trial on charges of manslaughter. A jury found the couple guilty in two hours.

  • A 5-year-old Hmong child has a cleft palate causing severe speech impairment. The family refuses surgical repair. The pediatrician considers this neglect and is seeking a court order. Should cultural differences be respected in decisions regarding health care to children? How is this different from a Christian Scientist refusing treatment for meningitis?

Learning objectives

After participating in this module, the learner will…

  1. Understand the components of informed consent or permission
  2. Understand the limitations of a parent’s right to refuse treatment for a child
  3. Identify the steps one must take to justify involving state agencies to compel treatment of a child
  4. Recognize the conflict between the parent’s values and those brought to the situation by medical professionals, and identify strategies for resolving this conflict

Suggested reading for instructor

Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;95(2):314-317.

Committee on Bioethics, American Academy of Pediatrics. Religious exemptions from child abuse statutes. Pediatrics. 1988;81:169-171.

Committee on Bioethics, American Academy of Pediatrics. Religious objections to medical care. Pediatrics. 1997;99:279-281.

Diekema, DS. Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theoretical Medicine and Bioethics. 2004;25(4):243-64.

Sheldon M. Ethical issues in the forced transfusion of Jehovah’s Witness children. J Emerg Med. 1995;14:251-257.

Swan R. Faith healing, Christian Science, and the medical care of children. The New England Journal of Medicine. 1983;309:1639-1641.

Religious, Cultural and Philosophical Objections to Medical Care:

Case discussion

This instructor’s guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital.

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