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In Reply

Baylor College of Medicine, Houston, TX

Angela M. Ethier

Center for Clinical Research, Texas Children's Hospital, Houston, TX

Ernest Frugé

Texas Children's Cancer Center and Baylor College of Medicine, Houston, TX

Laurence B. McCullough

Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX

Marilyn Hockenberry

Center for Nursing Research, Baylor College of Medicine, Houston, TX

We appreciate Dr André's thoughtful comments. We agree completely that it is important to include children in decisions about their medical care. Our abbreviated discussion¹ of this topic reflected space constraints rather than any lack of support for children's rights to be heard. Nonetheless, it is not accurate to characterize our model as treating parents and child as "one actor." We stated clearly that parents' "ethical authority is increasingly shared with the child as the child matures, for children have a right to express their opinions and to have those opinions taken into account in making treatment decisions."

Dr André asks several insightful questions about decisional authority, decisional priority, and legal authority. Decisional authority is the power or right to make a decision. In the case of infants, this right is held by the parents; children's claim on decisional authority grows as they mature. We therefore emphasized the concept of pediatric assent in our model. In cases of disagreement of the sort identified by Dr André, respect for pediatric assent, as the Committee on Bioethics of the American Academy of Pediatrics makes clear, requires the pediatric oncologist to advocate for a child's preferences when they are sufficiently mature and adult-like.²

Decisional priority is assumed by the person who first identifies one choice as being perhaps the best. This is a tentative but still significant step. Decisional priority can be assumed by any person, not just the family and the clinician, but also by others such as social workers, members of the clergy, nurses, and friends; in every case, decisional authority still remains with the family. When a parent says, "My mother told me that Carissa had suffered enough and it was time to stop chemotherapy, and I realized she was right," she describes a grandmother who has assumed decisional priority.

Finally, legal authority remains with the parents until the child is emancipated or reaches the age of majority. However, parental legal and decisional authority is not absolute even for infants. In the United States, for instance, parents' choices must be consistent with the best interests of the child. While the "best interests" standard is sometimes difficult to apply, if the parents reject treatment that is likely to cure a child with cancer their decision is likely to be overturned in court.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

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REFERENCES

1. Whitney SN, Ethier AM, Fruge E, et al: Decision making in pediatric oncology: Who should take the lead? The decisional priority in pediatric oncology model. J Clin Oncol 24:160-165, 2006[Abstract/Free Full Text]

2. American Academy of Pediatrics Committee on Bioethics: Informed consent, parental permission, and assent in pediatric practice. Pediatrics 95:314-317, 1995[Abstract/Free Full Text]

Related Correspondence

• Decisional Priority in Pediatric Oncology Revisited: Involving Children in Decision Making
  Nicolas André
  JCO 2006 24: 2131 [Full Text]

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