This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Whitney, S. N. Articles by Hockenberry, M. Search for Related Content PubMed Articles by Whitney, S. N. Articles by Hockenberry, M. Related Articles Related Correspondence Social Bookmarking                            What's this?

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.

Hand-Foot Syndrome After Dose-Dense Adjuvant Chemotherapy for Breast Cancer: A Case Series

Aditya Bardia, Charles L. Loprinzi, and Matthew P. Goetz e18

Treatment of Metastatic Renal Cell Carcinoma With Autologous T-Lymphocytes Genetically Retargeted Against Carbonic Anhydrase IX: First Clinical Experience

Cor H.J. Lamers, Stefan Sleijfer, Arnold G. Vulto, Wim H.J. Kruit, Mike Kliffen, Reno Debets, Jan W. Gratama, Gerrit Stoter, and Egbert Oosterwijk e20

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]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

Related Correspondence

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

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Whitney, S. N. Articles by Hockenberry, M. Search for Related Content PubMed Articles by Whitney, S. N. Articles by Hockenberry, M. Related Articles Related Correspondence Social Bookmarking                            What's this?