Ethical issues in managing the noncompliant child

Resident’s Name: Chad Abby Date: 9/19/2008
Article title: Ethical issues in managing the noncompliant child
Author(s): Ann L. Griffen, Lawrence J. Schneiderman
Journal: Pediatric Dentistry
Volume (number): Volume 14, Number 3
Month, Year: May/June 1992
Major topic: Behavior Management
Minor topic(s): ethical issues in behavior management techniques
Type of Article: Case review
Main Purpose: How best to handle patients who refuse dental treatment.
Overview of method of research: To help answer the question for behavior management interventions five areas of consideration were analyzed – the indications for treatment, patient autonomy, the benefits of dental treatment versus the burdens of a management intervention, the desires of parents, and external factors such as allocation of resources. Cases were presented and appropriate action discussed.
Findings: Children are not granted the legal autonomy, or right to refuse or consent to treatment (under 18) because they may not be competent to act in their own best interests. However, we need to seek the child’s assent to treatment in combination with permission of the parent or guardian. Assent asks that pediatricians involve children to participate in making decisions about their health and health care to the extent that they are able. Studies have shown that children under the age of seven have very little capacity to appreciate the consequences of treatment options. The estimation of capacity and determination of level of involvement in decision making lie within the judgment of the health professional. When deciding to use a management technique, the associated risks must be assessed. 1 in 10,000 of all anesthetized patients die of causes primarily attributal to anesthesia, although the risk to healthy patients is considerably lower. This risk is less than that of one year of normal automobile travel during which death rates are 2 in 10,000 persons. If parents refuse all reasonable treatment options offered, the dentist is obligated to attempt to educate to overcome ungrounded fears or misapprehensions. In cases of failure to obtain needed dental treatment, the dentist may be obligated to report the neglect to the appropriate agency to protect the child. At times economic factors may limit the use of general anesthesia for many patients, often those who need it most. The dentist’s obligation is to the patient, and considerations of public expense and attempts to ration or allocate scarce or limited resources ideally should be dealt with at a policy-making level and should not enter into individual treatment decisions.
Key points/Summary: Patient autonomy, or the right of self-determination, including the right to refuse treatment, is a fundamental right of all competent patients. Often as pediatric dentists we need to make this choice for the child because they may be incapable of appreciating the consequences of their choices. The following areas should be considered ethical decision making when a patient refuses treatment: Indications-carefully reconsider the urgency of the dental needs and determine if treatment can be delayed or avoided with no lasting ill effects; Assent- estimate the capacity of the child to participate in decision making, and involve the child to the extent of that capacity; Benefits versus burdens- determine what management techniques are likely to make treatment possible in a given situation; Permission- obtain parents’ permission after presenting a description of the recommended techniques, alternatives, and an assessment of the risks associated with refusing treatment; External factors- pediatric dentists have a responsibility to attempt to shape policy to make care more available on the basis of need as part of an overall system of justly distributed health care.
Assessment of article: Great article to review once in a while