Whose harm? Which metaphysic?

Douglas Diekema has argued that it is not the best interest standard, but the harm principle that serves as the moral basis for ethicists, clinicians, and the courts to trigger state intervention to limit parental authority in the clinic. Diekema claims the harm principle is especially effective in justifying state intervention in cases of religiously motivated medical neglect in pediatrics involving Jehovah’s Witnesses and Christian Scientists. I argue that Diekema has not articulated a harm principle that is capable of justifying state intervention in these cases. Where disagreements over appropriate care are tethered to metaphysical disagreements (as they are for Jehovah’s Witnesses and Christian Scientists), it is moral-metaphysical standards, rather than merely moral standards, that are needed to provide substantive guidance. I provide a discussion of Diekema’s harm principle to the broader end of highlighting an inconsistency between the theory and practice of secular bioethics when overriding religiously based medical decisions. In a secular state, ethicists, clinicians, and the courts are purportedly neutral with respect to moral-metaphysical positions, especially regarding those claims considered to be religious. However, the practice of overriding religiously based parental requests requires doffing the mantle of neutrality. In the search for a meaningful standard by which to override religiously based parental requests in pediatrics, bioethicists cannot avoid some minimal metaphysical commitments. To resolve this inconsistency, bioethicists must either begin permitting religiously based requests, even at the cost of children’s lives, or admit that at least some moral-metaphysical disputes can be rationally adjudicated.

     

Revisiting the best interest standard: uses and misuses

The best interest standard is the threshold most frequently employed by physicians and ethics consultants in challenging a parent's refusal to provide consent for a child's medical care. In this article, I will argue that the best interest standard has evolved to serve two different functions, and that these functions differ sufficiently that they require separate standards. While the best interest standard is appropriate for choosing among alternative treatment options for children, making recommendations to parents, and making decisions on behalf of a child when the legal decision makers are either unable to make a decision or are in dispute, a different standard is required for deciding when to seek state interference with parental decision-making authority. I will suggest that the harm principle provides a more appropriate threshold for determining when to seek state intervention than the best interest standard.     

Socio-cultural variation in attitudes to adolescents’ decision-making

Little is known about cultural variation in perceptions about the age when youngsters should be regarded as competent to make decisions. This is of particular importance as research has shown the significant effect of parental influence on their children’s decision-making. A public survey of 400 adults from diverse socio-cultural backgrounds in the UK and Spain was carried out. Their attitudes regarding adolescents’ ability with regard to common areas of decision-making were assessed using case vignettes including discontinuing family traditions and religious practice. It was found that White British adults agreed for younger adolescents to make decisions about themselves compared with the other ethnic groups. High religious practice was associated with later age to make decisions. The paper argues that there is socio-cultural variation in adults’ attitudes regarding the age when youngsters should make decisions about themselves and for the need of professionals to take this into account.     

Decoupling Marriage and Parenting

This article argues for separating the institutions of marriage and parenting, conceptually and legally. Marriage is neither necessary nor adequate for fostering cooperative and stable co‐parenting. Because promoting marriage fails to protect all children, the state should develop a more suitable formal mechanism whereby co‐parents can commit to cooperate in good faith in order to best serve the interests of their children. Like civil marriage, many of the terms of these contracts are aspirational and not enforceable, though they can guide arrangements for custody and financial support. Co‐parenting agreements need not be limited to two parents, nor need they be limited to legal parents, but can include de facto parents, such as stepparents, foster parents, and other support parents. One important aim of these agreements is to recognise and support the valuable work that married or unmarried co‐parents perform, and to protect the parental rights of caregivers in different kinds of situations.     

Parent–Child Roles in Decision Making About Medical Research

Our objective is to understand how parents and children perceive their roles in decision making about research participation. Forty-five children (ages 4–15 years) with or without a chronic condition and 21 parents were the participants. A semistructured interview assessed perceptions of up to 4 hypothetical research scenarios with varying levels of risk, benefit, and complexity. Children were also administered the Peabody Picture Vocabulary Test, Third Edition, to assess verbal ability, as a proxy for the child's cognitive development. The audiotaped interviews were transcribed and analyzed for themes related to parent and child decision-making roles. Both parents and children varied in their perceptions of decision-making roles. Child perceptions of parental influence on decision making as knowledge-based increased with cognitive development, whereas perceptions of parental influence as power-based decreased. Both children and parents commented that they would collaborate with each other when making decisions. Collaborative decision making appeared to increase with cognitive development. These findings suggest that approaches to child assent and parent permission should consider the parent–child relationship and how children and families typically make decisions. Future research is necessary to explain variation in the process of research decision making across children and families, explore the role of collaboration on children's decision-making skills, and understand developmental trajectories and mechanisms related to research decision making.     

Who should manage care? The case for patients

After establishing that it is essential that health care be rationed in some fashion, the paper examines the arguments for and against clinicians as gatekeepers. It first argues that bedside clinicians do not have the information needed to make allocation decisions. Then it claims that physicians at the bedside can be expected to make the wrong choice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will produce only very marginal benefit and could do much more good elsewhere) and their values will lead them to calculate the net value of treatments incorrectly. Alternative decision makers are considered. It is argued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and efficient rationing by patients at the societal and individual level are examined.     

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill’s “harm principle” should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill’s harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.     

In Defence of State Directed Enhancement

This article considers the ways in which a liberal society ought to view the potential to cognitively or physically enhance children. At present, the dominant approach in the literature is to leave this decision to parents. I suggest that the parental choice approach is often inadequate and fails to account properly for the interests of children and wider society in enhancement decisions. Instead I suggest that the state should play a greater role in determining when, and how, to enhance. To make this case, I compare the case of enhancement with existing practices of education, an area in which the state already plays a significant role. Finally I suggest that some concerns with a statist approach are not as serious as has been argued.     

Parents' Involvement in ASD Treatment: What Is Their Role?

The rising prevalence of autism spectrum disorders (ASD) warrants a greater level of clinical attention to best treat those with ASD. The characteristics of ASD lead to impairment for both the child with the disorder and his/her family. To effectively treat children with ASD, parents need to be included in intervention efforts. Research suggests that parental involvement in treatment improves the generalizability of skills and increases the amount of intervention the child receives. Numerous benefits have been found in child and parent outcomes when parents are included in treatment. The purpose of this paper is to discuss the impact ASD can have on the parent-child relationship, the factors that influence treatment outcome, and the advantages of including parents in treatment. The different roles parents can have in treatment will also be discussed along with providing clinicians guidance on practical ways to involve parents in the treatment of children with ASD.     

Helping parents deal with children's acute disciplinary problems without escalation: the principle of nonviolent resistance

There are two kinds of escalation between parents and children with acute discipline problems: (a) complementary escalation, in which parental giving-in leads to a progressive increase in the child's demands, and (b) reciprocal escalation, in which hostility begets hostility. Extant programs for helping parents deal with children with such problems focus mainly on one kind of escalation to the neglect of the other. The systematic use of Gandhi's principle of "nonviolent resistance" allows for a parental attitude that counters both kinds of escalation. An intervention is described, which allows parents to put this principle into practice.     

Enduring Positivity: Children Of Incarcerated Parents Report More Positive Than Negative Emotions When Thinking about Close Others

ABSTRACT

Millions of children in the United States experience parental incarceration, yet it is unclear how this experience might shape social cognition. We asked children of incarcerated parents (N = 24) and children whose parents were not incarcerated (N = 58) to describe their parents. Both groups of children also rated the extent to which they agree that they feel positive and, separately, negative emotions when thinking about their parent and best friend. This approach allowed us to test between two alternative hypotheses. On the one hand, cultural narratives in the United States convey negative messages about incarcerated people, and these messages could prompt children to report negativity when thinking about their incarcerated parents. On the other hand, children’s positivity toward close others is robust. Thus, when thinking about their incarcerated parents, children may report a great deal of positivity. Consistent with the latter possibility, children were more likely to describe their incarcerated parents using positive rather than negative terms. Moreover, children of incarcerated parents were more likely to agree that thinking about close others made them feel positive emotions than they were to agree that thinking about close others made them feel negative emotions. A similar pattern of results emerged among children whose parents were not incarcerated. These findings demonstrate the robustness of children’s positivity and can inform debates regarding contact between incarcerated parents and their children.     

Parent–child resemblance and kin investment: Physical resemblance or personality similarity?

Resemblance between parents and children has been suggested as an indicator of kinship. Because men, unlike women, cannot be certain about parenthood, resemblance may influence men more than women when making investment decisions. In the present paper we examine the relation of physical resemblance and personality similarity with parental investment for 90 Dutch parents and their school-age children. For mothers investment was linked to personality similarity, whereas for fathers investment was linked to physical resemblance, suggesting that fathers are influenced by physical cues when making investment decisions, whereas mothers are influenced by psychological cues.     

Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm

In this article, I argue that (1) transgender adolescents should have the legal right to access puberty-blocking treatment (PBT) without parental approval, and (2) the state has a role to play in publicizing information about gender dysphoria. Not only are transgender children harmed psychologically and physically via lack of access to PBT, but PBT is the established standard of care. Given that we generally think that parental authority should not go so far as to (1) severally and permanently harm a child and (2) prevent a child from access to standard physical care, then it follows that parental authority should not encompass denying gender-dysphoric children access to PBT. Moreover, transgender children without supportive parents cannot be helped without access to health care clinics and counseling to facilitate the transition. Hence there is an additional duty of the state to help facilitate sharing this information with vulnerable teens.     

Parental refusals of medical treatment: the harm principle as threshold for state intervention

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent's refusal to provide consent for a child's medical care. In this paper, I will argue that the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent's decision to refuse medical care on behalf of a child.     

Using a new analysis of the best interests standard to address cultural disputes: Whose data,which values?

Clinicians sometimes disagree about how much to honor surrogates’ deeply held cultural values or traditions when they differ from those of the host country. Such a controversy arose when parents requested a cultural accommodation to let their infant die by withdrawing life saving care. While both the parents and clinicians claimed to be using the Best Interests Standard to decide what to do, they were at an impasse. This standard is analyzed into three necessary and jointly sufficient conditions and used to resolve the question of how much to accommodate cultural preferences and how to treat this infant. The extreme versions of absolutism and relativism are rejected. Properly understood, the Best Interests Standard can serve as a powerful tool in settling disputes about how to make good decisions for those who cannot decide for themselves.     

Child Abuse: parental rights and the interests of the child

ABSTRACT I criticise the 'liberal'view of the proper relationship between the family and State, namely that, although the interests of the child should be paramount, parents are entitled to rights of both privacy and autonomy which should be abrogated only when the child suffers a specifiable harm. I argue that the right to bear children is not absolute, and that it only grounds a right to rear upon an objectionable proprietarian picture of the child as owned by its producer. If natural parents have any rights to rear they derive from duties to bring their children into rational maturity where they can exercise rights for themselves. The presumption that natural parents are best suited to rear their own children should be discounted, as should the assumption that alternatives to natural parenting are unacceptably bad. I reject the suggestion that parents should be 'licensed'but argue for a much closer monitoring of the family. Familial privacy, which such monitoring breaches, is shown to have a culturally specific and, given the facts of abuse, dubious value. In conclusion, I briefly specify the forms of monitoring I approve.     

Parental consent for psychological evaluations: Legal,ethical and practical considerations

This article explores the legal, ethical, and practical considerations underlying the requirement for acquiring parental consent prior to a psychological assessment of children in school settings. Publ. L. 94-142 now mandates that parents for all children potentially labeled as handicapped give permission for a preplacement evaluation. This article reviews in detail specific aspects of that mandate, argues that this procedure be generalized to all situations where psychologists propose to evaluate children by reviewing both current ethical codes and standards for practice and public policy which favors such an undertaking. Finally, the authors indicate methods for implementing the mandate by discussing such issues as who should obtain consent and what information parents should receive prior to giving consent.     

When Psychotherapy Is Not Working: Ethical Considerations

Evidence-based practice (EBP) models have been developed, in part, to enhance the likelihood that the outcome of health care treatment, including psychotherapy, leads to positive improvement. However, two additional outcomes can occur: no change and poor outcome (e.g., harm, worsening of symptoms). What does the clinician do when psychotherapy is not working? When faced with various treatment decisions, such as this, the EBP model posits that therapists should apply their clinical expertise in considering the “best available research” within the context of various patient characteristics. In part because of various limitations of this approach, I suggest that another important set of principles are important to consider in tandem when faced with this clinical dilemma—that is, ethical concerns. Borrowing from the American Psychological Association’s (2017a) Ethics Code, I discuss how the following issues exist when clinicians wrestle with this question: avoidance of harm, competence, conflicts of interest, and informed consent. I conclude this paper with a list of suggestions that can potentially foster the application of ethical principles when making treatment decisions.     

Parental manipulation of child behavior in home observations

The object of this study was to investigate the extent to which parents can manipulate their children's behavior in home observations. Twelve families with four- to six-year old children were recruited for the research. The parents were instructed to make their child look "bad" or "deviant" on three days of a six-day observation and to look "good" or "nondeviant" on alternate days. Results indicated that, as predicted, the rate of child deviant behavior, parental negative responding, and parental commands were all significantly higher on bad than good days. Parental responses to questionnaires provided more detailed information on how parents felt that they influenced their children in the desired directions. These results were discussed in terms of their implications for child psychopathology and the methodology of data collection in the natural environment.     

直升机教养的内涵、影响和后效

直升机教养是父母对始成年期青少年普遍采用的一种教养方式,它是指父母给孩子过度的支持,较多地控制其行为,并不能给予孩子适合其年龄的自主权的教养方式。本文从直升机教养的概念辨析、影响因素和作用后效方面进行了系统梳理和整合分析,未来研究需要扩展研究对象和内容、精细探讨直升机教养的作用机制、重视我国始成年人的直升机教养,深入考察直升机教养与健康成长的因果关系。