Dr Vizcarrondo has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Respecting an individual’s autonomy has become an overarching obligation in medical decision-making. In pediatrics, however, children are not autonomous individuals, since the right to self-determination – the core of autonomy – depends on cognitive, psychological, and social skills that children have yet to develop. For this reason, we rely on parents or legal guardians to act as the child’s surrogate and to abide by standards for surrogate decision-making. The most commonly used standard is the best interest standard: what is in the best interest of the child is determined by the surrogate calculating the benefits and burdens of a procedure or course of treatment with the goal of attaining the greatest benefit and least burden.

Salter1 characterizes the best interest standard practiced today as one that primarily focuses on weighing the benefits and burdens relevant to the child only and not those benefits and burdens relative to others, such as parents and family. Although this focus on the individual stresses the development of the child’s autonomy, it also requires parents to conceive of the child’s interests as separate from their interests. Salter states that the latter is unrealistic.

Salter asserts that the best interest standard ought to include consideration of benefits and burdens not only to the child but also to those on whom the child is dependent. Since a child cannot be sufficiently isolated from the influence of parents and family, Salter argues we ought not employ a standard for pediatric decision-making that considers the child as an isolated individual. She calls for including relationships and relational interests when making decisions for children.

Salter proposes 4 specific questions to be asked when considering a plan of care for a child: What are the likely consequences of the course of treatment on the child’s ability to (1) communicate with others, (2) engage physically with others, and (3) play or interact with others, and finally, (4) where and by whom will the child be cared for? She claims the language of rights and the rules derived from the principle of autonomy do have a place in pediatric decision-making, but are best placed in the context of setting the boundaries for state intervention. She proposes to call these the “basic” interests of the child, a public standard minimum threshold of care, below which the state is justified in intervening.

Salter’s call to expand the best interest standard in pediatric medical decision-making to include the relational interests of children would conform more closely to reality, enhance ethical deliberation, and may result in better outcomes for the child and the family.

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