This article critically examines, and ultimately rejects, the best interest standard as the predominant, go-to ethical and legal standard of decision making for children. After an introduction to the presumption of parental authority, it characterizes and distinguishes six versions of the best interest standard according to two key dimensions related to the types of interests emphasized. Then the article brings three main criticisms against the best interest standard: (1) that it is ill-defined and inconsistently appealed to and applied, (2) that (...) it is unreasonably demanding and narrow, and (3) that it fails to respect the family. Finally, it argues that despite the best interest standard’s potent rhetorical power, it is irreparably encumbered by too much inconsistency and confusion and should be rejected. (shrink)

The best-interests standard is a widely used ethical, legal, and social basis for policy and decision-making involving children and other incompetent persons. It is under attack, however, as self-defeating, individualistic, unknowable, vague, dangerous, and open to abuse. The author defends this standard by identifying its employment, first, as a threshold for intervention and judgment (as in child abuse and neglect rulings), second, as an ideal to establish policies or prima facie duties, and, third, as a standard of reasonableness. Criticisms of (...) the best-interests standard are reconsidered after clarifying these different meanings. (shrink)

Predictive genetic testing is now routinely offered to asymptomatic adults at risk for genetic disease. However, testing of minors at risk for adult-onset conditions, where no treatment or preventive intervention exists, has evoked greater controversy and inspired a debate spanning two decades. This review aims to provide a detailed longitudinal analysis and concludes by examining the debate's current status and prospects for the future. Fifty-three relevant theoretical papers published between 1990 and December 2010 were identified, and interpretative content analysis was (...) employed to catalogue discrete arguments within these papers. Novel conclusions were drawn from this review. While the debate's first voices were raised in opposition of testing and their arguments have retained currency over many years, arguments in favour of testing, which appeared sporadically at first, have gained momentum more recently. Most arguments on both sides are testable empirical claims, so far untested, rather than abstract ethical or philosophical positions. The dispute, therein, lies not so much in whether minors should be permitted to access predictive genetic testing but whether these empirical claims on the relative benefits or harms of testing should be assessed. (shrink)

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. (shrink)

Although deeply committed to the model of nondirective counseling, most genetic counselors enter the profession with certain assumptions about health and disability—for example, that it is preferable to be a hearing person than a deaf person. Thus, most genetic counselors are deeply troubled when parents with certain disabilities ask for assistance in having a child who shares their disability. This ethical challenge benefits little from viewing it as a conflict between beneficence and autonomy. The challenge is better recast as a (...) conflict between parental autonomy and the child's future autonomy. (shrink)

The maxim “parents should do what is in the best interests of their child” seems like an unassailable truth, and yet, as I argue here, there are serious problems with it when it is taken seriously. One problem concerns the sort of demands such a principle places on parents; the other concerns its larger social implications when conceived as part of a national policy for the rearing of children. The theory of parenting that creates these problems I call “optimizing parentalism.” (...) To avoid them, I define and defend a new and more morally appealing theory, “satisficing parentalism.”. (shrink)

In my dissertation, I examine the moral principles that guide health care decision making for children. Presently, parents make most of these decisions. The presumptive guiding principle is the "best interest standard." I argue that parents are the appropriate decision makers but that they should be guided by the Kantian principle of respect for persons, modified to apply to children who are not full persons. A modified principle of respect can be stated as follows: ;Children should never be treated solely (...) as a means, but always, at the same time, as potential persons and as individuals who have actualized some of the characteristics associated with personhood. vskip9pt ;This principle can be understood to include two overlapping components: a negative component which applies universally and which prohibits the abuse, neglect, and exploitation of children; and a positive component which only applies in particular relationships and which incorporates the duty to provide children with the Rawlsian primary goods necessary to become full persons capable of devising and implementing their own life plans. ;There is also the question of the proper role for children in the decision making process. Presently, there is a movement to increase the child's role and to make his or her assent binding. Mature minor, emancipated minor, and specialized consent statutes even allow children to make some decisions without parental notification. I argue that children should be included in the decision making process but that respect for family autonomy empowers parents to make decisions for their children even after they have achieved some threshold level of competency. Nevertheless, I do not reject the child's voice in all cases. Rather, I argue that as the potential benefits decrease and the potential harms increase, the child's decision must be binding. If the child is unable to assent or dissent, then his participation should be prohibited. ;Implementation of the health care decision making model that I propose would result in significant changes in what informed consent allows and requires for pediatric health care decisions. For example, I argue that Parents should have final decision making authority when the child's participation has direct therapeutic benefit; and The child's dissent ought to be binding in fewer scenarios than it presently is. (shrink)