Table 1.

Five ethical frameworks for assessing the permissibility of parental choices around medical care (modified and edited from McDougall and Notini⁹ and Gillam²⁹)

Ethical framework	Summary
Best Interests Kopelman8 Buchanan and Brock49	‘Acting to promote maximally the good of the individual (the child)’ • The state can over-ride the parents’ authority if the child has suffered or is in danger of suffering serious harm • Once that threshold is met, the state must decide on the course of action considering the child’s best interests
Harm Principle Diekema7	Health professionals can seek state intervention if: • The parents’ decision significantly increases the risk of harm • The harm is imminent • The refused intervention is necessary to prevent the harm • The refused intervention is of proven efficacy • The projected benefit to burden ratio of the refused intervention is significantly more favourable compared with that of the parents’ preferred option • No alternative would prevent harm and be more acceptable to the parents • Most parents would agree that state intervention was reasonable
The Not Unreasonable Standard Rhodes and Holzman31	Assess the appropriateness of the decision makers and assess the appropriateness of the decision itself • Centre core judgement: one that is universally made and cannot be reasonably rejected • Second domain judgement: one that is prioritised differently by reasonable people • Third domain judgement: one that can be reasonably rejected An idiosyncratic reason can only be accepted when a patient makes a decision for themselves, not when a surrogate makes a decision (eg, parents). ‘Only decisions based on universal reasons are acceptable for surrogate refusal of highly beneficial treatment.’
Balance of Cost and Benefits DeMarco et al 32	An economic theory which balances: • Cost of treatment for the patient • Benefit of treatment for the patient • Costs borne by others as a result of the treatment
Zone of Parental Discretion Gillam and Kilham et al 29 50	A practical tool which denotes an ‘ethically and legally protected space’ in which parents are allowed to make decisions for their children. It considers: • The Harm Principle (see above) • The burdensomeness of the intervention Compares the expected harms of acceding to the parents’ wishes with the harms involved in over-riding the parents’ wishes