Overruling parental decisions in paediatric medicine: A comparison of Diekema’s Harm Threshold Framework and the Zone of Parental Discretion Framework

Abstract

Background

The complexity of decision-making in the paediatric context is well recognised. In the majority of cases, parents and healthcare professionals work together to decide which treatments the paediatric patient should receive. On occasions, however, parental wishes conflict with what clinicians think is best for the paediatric patient. Where persistent disagreement between clinicians and parents exists, clinicians must ascertain if they have a moral, professional, and legal obligation to overrule the parents' decision and implement their preferred option.

Purpose

Few decision-making frameworks to assist in addressing the ethical issues that arise in clinical decision-making relate specifically to the paediatric context. Diekema's Harm Threshold Framework and the Zone of Parental Discretion (ZPD) Framework assist in determining whether parental decisions should or should not be overridden. This paper examines the similarities and differences between these frameworks.

Methods

The frameworks are analysed in terms of their underlying principles, scope, threshold for harm, mechanisms for resolving clinician/parental differences and mechanism(s) for overruling parental decisions. The ZPD Framework incorporates an additional component that is also considered in this paper.

Results

Similarities: Both frameworks use similar definitions of harm, consider the harms associated with overriding parental requests, and, ultimately, resort to state intervention as the mechanism for overruling parental decisions but only as a last resort. Differences: The ZPD Framework is broader in scope and has a far lower harm threshold than Diekema's Harm Threshold Framework. Diekema's Framework relies exclusively on the Harm Principle and is used exclusively for parental refusals to treatment whereas the ZPD Framework also incorporates the Best Interests Standard and can be used for parental refusals as well as requests for treatment that clinicians consider potentially harmful.

Conclusion

While the frameworks share similarities, there are also considerable differences. This analysis highlights the theoretical differences and helps identify which framework may be most useful to clinicians and ethicists in specific cases.