Introduction: principles

In children, respect for autonomy is secondary to an obligation to consider a child’s interests and to make them paramount.1 What happens to the child will inevitably impact on the whole family.2 A parent’s exercise of personal autonomy does not, however, extend directly to making decisions about a child, because, whether or not she can express them, the child has some interests which are separable from those of her parents.

Where the child herself cannot express those interests, they must be articulated by surrogate decision-makers. ‘Interests’ encompasses medical outcomes, such as chance of recovery, as well as wider benefits and harms in social, emotional and spiritual domains. While doctors are qualified to evaluate some interests, it is parents who are best placed to evaluate others. Furthermore, a child’s interests are usually best served by a collegiate relationship between parents and paediatrician and are jeopardised by any breakdown in that relationship.3 For both reasons, if a child’s interests are to be made paramount, paediatricians must ensure parents are invited to help evaluate what those interests are.

In this article, I argue that the paediatrician’s obligations go beyond resolving conflict between acting in a child’s interests and respecting her parents’ autonomy. I suggest that paediatricians are under a third obligation, that of truth telling, which requires them to be honest with a child’s parents and to make clear from the outset that decisions about their child must be made in dialogue with the healthcare team. I propose four practical ways in which the paediatrician can meet the obligations of all three ethical principles.