Navigating Informed Consent When Working with Children

Consent for procedures and understanding treatment options takes on some nuance when working with a pediatric population. Informed consent was designed with the guiding principle that patients should be able to make their own decisions regarding their medical care. But what happens when a patient is a child and may lack the autonomy to decide their own care?

A recent article examined this issue in the setting of dermatology clinics and sought to answer the question of how to ethically obtain informed consent from children while being mindful that in some cases all the parties involved may not agree. The authors offer some guidance for handling situations where the clinician, patient, and parents’ views regarding the patient’s best interest do not align:

Problem: Parents feel strongly that a procedure should be done, but the clinician does not agree and the child does not want the treatment. The authors suggest that the clinician should come to a mutually agreed on plan or compromise that they both feel is in the patient’s best interest. However, they note that ultimately, the parent has legal authority, regardless of the wishes of the minor. In this case, clinicians are not obligated to perform procedures that they feel are not in the patient’s best interest and may best be advised to refer out.

Problem: The adolescent patient is insisting on a procedure or course of treatment that the parent (or clinician) does not feel is best or refusing one that the clinician and parents want them to consider. As pediatric patients enter adolescence, their views and opinions will play an increasing role in dictating their medical care. While teens may be able to comprehend risks and benefits of an intervention, their ability to control their impulses may be underdeveloped, causing them to make more risky and potentially harmful decisions. It is advised that if an adolescent demands treatment that the parent and clinician feel is not clinically indicated, or for which the risks outweigh the benefits, it is reasonable to refuse. However, if the patient refuses an intervention that is not essential or can be postponed without significant risk, then serious consideration should be given to that refusal.

Problem: The clinician and parent agree on a necessary procedure but the child does not want it and protests. If the child does not have the capacity to understand risk, the procedure may have to proceed without their consent. But, if the harm-to-benefit ratio is skewed towards less harm to the patient, patients should not be forced to endure potentially frightening or painful treatments without their cooperation.

The authors use these scenarios to underscore the types of ethical dilemmas that may arise when the patient include a third party present in the exam room. They suggest that when there is disagreement on the “best” course of action for the patient among the three parties, the dermatology provider should first consider pertinent local laws and then consider a basic ethical and legal framework for navigating these challenging cases.