More than 20 years ago, the pioneering pediatric ethicist William Bartholome1  wrote a fiery letter to the editor of this journal because he thought a recently published statement on pediatric assent, from the Committee on Bioethics of the American Academy of Pediatrics (AAP), showed insufficient respect for children.2  That AAP statement, like its 2016 update, asserts that pediatric assent should be solicited only when a child’s dissent will be honored.3,4  Bartholome1  objected that pediatricians should always solicit children’s assent and that they should acknowledge and apologize when they treat children over their objections even when they must do so to promote children’s best interests.

We think Bartholome1  was right. In this brief commentary, we elaborate on his perspective about the moral value of pediatric assent, and we suggest improvements to the corresponding clinical guidance.

The AAP grounds the moral value of pediatric assent by noting, “We are obliged to act out of fundamental respect for other persons by virtue of their personal autonomy.” But in drawing on the concept of autonomy, the AAP invokes too narrow a conception of respect. Indeed, the AAP acknowledges that many children “lack the agency required to be truly autonomous agents.”3  If respect is grounded on autonomy, and if autonomy is what enables preferences to be authoritative, then perhaps it would be disrespectful to solicit preferences in situations in which a child’s dissent will not be honored. However, respect is about more than autonomy. In keeping with Bartholome’s concerns, a broader conception of respect supports a more stable commitment to pediatric assent.

Respect is something we owe to others as a way to demonstrate that we recognize them as persons rather than objects. Patients (including children) are persons even if they do not reason well, particularly if they have a kind of agency that is capable of expressing preferences.5,6  One way to respect persons is to acknowledge that their preferences matter, something that may require soliciting those preferences, even in cases in which it would be ethically wrong to give them what they prefer. This is because it is disrespectful, and perhaps even dehumanizing, to treat preference-expressing patients as mere bystanders or obstacles to their own care.

Pediatricians are often permitted, and sometimes obligated, to treat children over their objections. Whether a child’s preferences should be overridden in a particular case depends, among other things, on the child’s capacity to reason, but the preferences of even young or cognitively impaired children always have some moral value. Because a child’s preferences always have moral weight, even when it is right to set them aside, treating a child over objection always creates a residual moral harm that can be recognized through apology. This view underscores the importance of respecting children as persons and it honors the moral complexity of pediatrics, in which actions that ultimately may be right can have morally regrettable aspects.

At its core, pediatric assent is about soliciting children’s preferences about treatment, in both discrete encounters or longitudinal contexts, in which preferences may shift and evolve. Consider the following case.

Dr G.S. is a pediatrician seeing 4-year-old M.M., whose mother brought him to the clinic to have an abscess in his axilla lanced after attempting to treat it with hot compresses. On seeing the needle for the local anesthetic, M.M. begins to cry. Dr G.S. asks, “You do not want the shots, do you?” and M.M. says, “No! Needles hurt!” Dr G.S. replies, “I know, but this little lump is an infection, and we need to get that pus out to keep you healthy. So, we have to do it.” M.M. begins flailing his arms and legs, and Dr G.S. indicates that his mother should restrain him. M.M. struggles and screams, “No, no!” Just before the injection, the doctor says, “I’m sorry about this buddy.” M.M.’s mother keeps him restrained while Dr G.S. incises the abscess, irrigates it, and packs the wound. Afterward, M.M. continues to sob quietly, but he seems content by the time he leaves the clinic.

This may seem like an unremarkable scenario. But its routine nature obscures its ethical complexity and the subtle and important moral work of pediatricians, particularly in navigating between children’s best interest and demonstrating respect for their preferences.

Many organizations and advocates in pediatric ethics contend that a child’s assent should not be solicited in cases of inevitable treatment.5  One implication is that a child may feel deceived if their solicited preferences are overridden. But there is little reason to think that solicitations of patient preferences, when done properly (as we presume Dr G.S. does), invite children to expect their preferences to be fulfilled. Indeed, it is common for pediatricians to be explicit about the limits of their ability to fulfill patients’ preferences, for example, when they promise confidentiality to child patients. Furthermore, it is often difficult or impossible to avoid soliciting children’s preferences because all children, even those who are young or severely impaired, often offer spontaneous expressions of their preferences. For example, M.M. objects to his treatment even before Dr G.S. can inquire about M.M.’s preferences. These sorts of interactions are common in pediatrics, and their prevalence may reflect a widespread clinical intuition about what it means to respect children and value their preferences in cases of inevitable treatment.

Pediatricians can demonstrate respect for children in many ways, including disclosing appropriate information and maintaining respectful communication. However, the practice of pediatric assent is a particularly important mechanism for demonstrating respect because it encourages the child’s active engagement in their care. The AAP can strengthen its efforts to promote respect for children by encouraging pediatricians to solicit assent even in cases of inevitable treatment and to express regret for treatment over objection even when it is justified.

In practice, many pediatricians solicit their patients’ assent and apologize if they cannot give children what they want. Even if these reflect mere habits of speech, they may indicate an important professional virtue: a disposition to treat patients with respect.7  At its best, soliciting the preferences of children represents a form of epistemic humility, an acknowledgment that there is at least some possibility that what the child patient says will have a meaningful impact on their care, even when we think the treatment decision is a foregone conclusion. And we suspect that pediatricians’ tendency to apologize for coercive treatment also reflects their desire to acknowledge the moral wrongs committed in the pursuit of what is ultimately the morally right thing to do. This echoes the wisdom in Bartholeme’s1  decades-old criticism: apologies demonstrate respect, and they are a means to honor a patient’s objection without making that objection authoritative. Such an apology is not a concession of moral failure or an expression of guilt but a recognition that a morally appropriate course of action can involve subsidiary moral wrongs. We advocate for efforts to strengthen AAP guidance on pediatric assent and recommend that pediatricians solicit children’s preferences whenever possible and that they apologize for justified instances of treatment over objection. Such additions to AAP policy would honor the moral complexity of pediatrics and strengthen the AAP’s longstanding commitment to respecting children.

Dr Wasserman conceptualized the arguments in the article and drafted the initial manuscript; Drs Navin and Vercler conceptualized the arguments in the article; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • AAP

    American Academy of Pediatrics

1
Bartholome
WG
.
Informed consent, parental permission, and assent in pediatric practice
.
Pediatrics
.
1995
;
96
(
5, pt 1
):
981
982
2
AAP Committee on Bioethics
.
Informed consent, parental permission, and assent in pediatric practice. Committee on Bioethics, American Academy of Pediatrics
.
Pediatrics
.
1995
;
95
(
2
):
314
317
3
Katz
AL
,
Webb
SA
;
Committee on Bioethics
.
Informed consent in decision-making in pediatric practice
.
Pediatrics
.
2016
;
138
(
2
):
e20161485
4
Committee on Bioethics
.
Informed consent in decision-making in pediatric practice
.
Pediatrics
.
2016
;
138
(
2
):
e20161484
5
Navin
MC
,
Wasserman
JA
.
Capacity for preferences and pediatric assent implications for pediatric practice
.
Hastings Cent Rep
.
2019
;
49
(
1
):
43
51
6
Wasserman
JA
,
Navin
MC
.
Capacity for preferences: respecting patients with compromised decision-making
.
Hastings Cent Rep
.
2018
;
48
(
3
):
31
39
7
Pellegrino
ED
,
Thomasma
DC
.
The Virtues in Medical Practice
.
New York, NY
:
Oxford University Press
;
1993

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.