Editing Pediatrics (section)

== Pediatric autonomy in healthcare ==
A major difference between the practice of pediatric and adult medicine is that children, in most [[jurisdiction]]s and with certain exceptions, cannot make decisions for themselves. The issues of [[guardianship]], privacy, legal responsibility, and informed consent must always be considered in every pediatric procedure. Pediatricians often have to treat the parents and sometimes, the family, rather than just the child. Adolescents are in their own legal class, having rights to their own health care decisions in certain circumstances. The concept of legal consent combined with the non-legal consent (assent) of the child when considering treatment options, especially in the face of conditions with poor prognosis or complicated and painful procedures/surgeries, means the pediatrician must take into account the desires of many people, in addition to those of the patient.{{cn|date=August 2024}}

=== History of pediatric autonomy ===
The term autonomy is traceable to ethical theory and law, where it states that autonomous individuals can make decisions based on their own logic.<ref>{{Cite journal|last1=Katz|first1=Aviva L.|last2=Webb|first2=Sally A.|last3=COMMITTEE ON BIOETHICS|last4=Macauley|first4=Robert C.|last5=Mercurio|first5=Mark R.|last6=Moon|first6=Margaret R.|last7=Okun|first7=Alexander L.|last8=Opel|first8=Douglas J.|last9=Statter|first9=Mindy B.|date=2016-08-01|title=Informed Consent in Decision-Making in Pediatric Practice|journal=Pediatrics|volume=138|issue=2|pages=e20161485|doi=10.1542/peds.2016-1485|pmid=27456510|s2cid=7951515|issn=0031-4005|doi-access=free}}</ref> Hippocrates was the first to use the term in a medical setting. He created a code of ethics for doctors called the ''[[Hippocratic Oath]]'' that highlighted the importance of putting patients' interests first, making autonomy for patients a top priority in health care.<ref name=":22">{{Cite book|date=2020|editor-last=Mazur|editor-first=Kate A.|editor2-last=Berg|editor2-first=Stacey L.|title=Ethical Issues in Pediatric Hematology/Oncology|url=https://doi.org/10.1007/978-3-030-22684-8|language=en-gb|pages=13–21|doi=10.1007/978-3-030-22684-8|isbn=978-3-030-22683-1|s2cid=208302429}}</ref>   

In ancient times, society did not view pediatric medicine as essential or scientific.<ref name=":14">{{Cite book|last1=Stern|first1=Alexandra Minna|url=https://www.fulcrum.org/concern/monographs/dn39x232m|title=Formative Years: Children's Health in the United States, 1880-2000|last2=Markel|first2=Howard|date=2002|publisher=University of Michigan Press|isbn=978-0-472-02503-9|pages=23–24|language=en|doi=10.3998/mpub.17065|access-date=30 November 2021|archive-date=30 November 2021|archive-url=https://web.archive.org/web/20211130164350/https://www.fulcrum.org/concern/monographs/dn39x232m|url-status=live}}</ref> Experts considered professional medicine unsuitable for treating children. Children also had no rights. Fathers regarded their children as property, so their children's health decisions were entrusted to them.<ref name=":4" /> As a result, mothers, midwives, "wise women", and general practitioners treated the children instead of doctors.<ref name=":14" /> Since mothers could not rely on professional medicine to take care of their children, they developed their own methods, such as using alkaline soda ash to remove the vernix at birth and treating teething pain with opium or wine. The absence of proper pediatric care, rights, and laws in health care to prioritize children's health led to many of their deaths. Ancient Greeks and Romans sometimes even killed healthy female babies and infants with deformities since they had no adequate medical treatment and no laws prohibiting infanticide.<ref name=":4" />

In the twentieth century, medical experts began to put more emphasis on children's rights. In 1989, in the United Nations Rights of the Child Convention, medical experts developed the Best Interest Standard of Child to prioritize children's rights and best interests. This event marked the onset of pediatric autonomy. In 1995, the [[American Academy of Pediatrics]] (AAP) finally acknowledged the Best Interest Standard of a Child as an ethical principle for pediatric decision-making, and it is still being used today.<ref name=":22" />

=== Parental authority and current medical issues ===
The majority of the time, parents have the authority to decide what happens to their child. Philosopher John Locke argued that it is the responsibility of parents to raise their children and that God gave them this authority. In modern society, Jeffrey Blustein, modern philosopher and author of the book ''Parents and Children: The Ethics of Family'', argues that parental authority is granted because the child requires parents to satisfy their needs. He believes that parental autonomy is more about parents providing good care for their children and treating them with respect than parents having rights.<ref>{{Cite book|last=Friedman|first=Lainie Ross|url=http://worldcat.org/oclc/756393117|title=Children, families, and health care decision making|date=2004|publisher=Clarendon Press|isbn=0-19-925154-1|oclc=756393117}}</ref> The researcher Kyriakos Martakis, MD, MSc, explains that research shows parental influence negatively affects children's ability to form autonomy. However, involving children in the decision-making process allows children to develop their cognitive skills and create their own opinions and, thus, decisions about their health. Parental authority affects the degree of autonomy the child patient has. As a result, in Argentina, the new National Civil and Commercial Code has enacted various changes to the healthcare system to encourage children and adolescents to develop autonomy. It has become more crucial to let children take accountability for their own health decisions.<ref name=":3">{{Cite journal|last1=Martakis|first1=K.|last2=Schröder-Bäck|first2=P.|last3=Brand|first3=H.|date=2018-06-01|title=Developing child autonomy in pediatric healthcare: towards an ethical model|journal=Archivos Argentinos de Pediatria|volume=116|issue=3|pages=e401–e408|doi=10.5546/aap.2018.eng.e401|pmid=29756714|s2cid=46889502|issn=0325-0075|doi-access=free}}</ref>

In most cases, the pediatrician, parent, and child work as a team to make the best possible medical decision. The pediatrician has the right to intervene for the child's welfare and seek advice from an ethics committee. However, in recent studies, authors have denied that complete autonomy is present in pediatric healthcare. The same moral standards should apply to children as they do to adults. In support of this idea is the concept of paternalism, which negates autonomy when it is in the patient's interests. This concept aims to keep the child's best interests in mind regarding autonomy. Pediatricians can interact with patients and help them make decisions that will benefit them, thus enhancing their autonomy. However, radical theories that question a child's moral worth continue to be debated today.<ref name=":3" /> Authors often question whether the treatment and equality of a child and an adult should be the same. Author [[Tamar Schapiro]] notes that children need nurturing and cannot exercise the same level of authority as adults.<ref>{{Cite journal|last=Schapiro|first=Tamar|date=1999-07-01|title=What Is a Child?|url=https://www.journals.uchicago.edu/doi/10.1086/233943|journal=Ethics|volume=109|issue=4|pages=715–738|doi=10.1086/233943|s2cid=170129444|issn=0014-1704|access-date=30 November 2021|archive-date=30 November 2021|archive-url=https://web.archive.org/web/20211130162622/https://www.journals.uchicago.edu/doi/10.1086/233943|url-status=live}}</ref> Hence, continuing the discussion on whether children are capable of making important health decisions until this day.

=== Modern advancements ===
According to the Subcommittee of Clinical Ethics of the Argentinean Pediatric Society (SAP), children can understand moral feelings at all ages and can make reasonable decisions based on those feelings. Therefore, children and teens are deemed capable of making their own health decisions when they reach the age of 13. Recently, studies made on the decision-making of children have challenged that age to be 12.<ref name=":3" />

Technology has made several modern advancements that contribute to the future development of child autonomy, for example, unsolicited findings (U.F.s) of pediatric exome sequencing. They are findings based on pediatric exome sequencing that explain in greater detail the intellectual disability of a child and predict to what extent it will affect the child in the future. Genetic and intellectual disorders in children make them incapable of making moral decisions, so people look down upon this kind of testing because the child's future autonomy is at risk. It is still in question whether parents should request these types of testing for their children. Medical experts argue that it could endanger the autonomous rights the child will possess in the future. However, the parents contend that [[genetic testing]] would benefit the welfare of their children since it would allow them to make better health care decisions.<ref>{{Cite journal|last1=Dondorp|first1=W.|last2=Bolt|first2=I.|last3=Tibben|first3=A.|last4=De Wert|first4=G.|last5=Van Summeren|first5=M.|date=2021-09-01|title='We Should View Him as an Individual': The Role of the Child's Future Autonomy in Shared Decision-Making About Unsolicited Findings in Pediatric Exome Sequencing|url=https://doi.org/10.1007/s10728-020-00425-7|journal=Health Care Analysis|language=en|volume=29|issue=3|pages=249–261|doi=10.1007/s10728-020-00425-7|pmid=33389383|s2cid=230112761|issn=1573-3394}}</ref> Exome sequencing for children and the decision to grant parents the right to request them is a medically ethical issue that many still debate today.