Mark Navin

Reasons to Amplify the Role of Parental Permission in Pediatric Treatment

Two new documents from the Committee on Bioethics of the American Academy of Pediatrics (AAP) expand the terrain for parental decision making, suggesting that pediatricians may override only those parental requests that cross a harm threshold. These new documents introduce a broader set of considerations in favor of parental authority in pediatric care than previous AAP documents have embraced. While we find this to be a positive move, we argue that the 2016 AAP positions actually understate the importance of informed and voluntary parental involvement in pediatric decision making. This article provides a more expansive account of the value of parental permission. In particular, we suggest that an expansive role for parental permission may (1) reveal facts and values relevant to their childs treatment, (2) encourage resistance to suboptimal default practices, (3) improve adherence to treatment, (4) nurture childrens autonomy, and (5) promote the interests of other family members.

Harm and Parental Permission: A Response to Our Critics

We worried that our article (Navin and Wasserman 2017) would be uninteresting. We thought our task was perhaps too small: complementing (and complimenting) recent AAP guidelines (Katz, Webb, and AAP Committee on Bioethics 2016; AAP Committee on Bioethics 2016), by identifying additional reasons to value parental permission in the care of child patients. We suspected that most responses to our article would be like those offered by Nate Olson, who thinks we were “preaching to the converted” when we identified a broader set of moral reasons to value parental involvement in pediatric medical decision making (Olson 2017). We even expressed something like this view in our article, when we speculated that “most physicians are already promoting parental permission and that they are doing so for many of the reasons we articulate here” (Navin and Wasserman 2017). Our article proposed no changes to clinical practice or to the recent AAP statements to which we refer. Instead, we affirmed what we saw as a shift (perhaps primarily in emphasis) between the AAP’s 1995 statement (AAP Committee on Bioethics 1995) and the 2016 updates: the new guidelines identify the harm threshold as a location for physician interference in parental participation in pediatric decision making. We did not argue for this thesis in our article. Rather, we identified additional reasons to value parental permission, other than those that the new AAP statement identified. We are pleased, however, that our article generated such passionate critical discussion from experts in pediatric ethics, and we are grateful for the chance to respond. However, some of our critics have misread our position, or they have reasoned to conclusions that are inconsistent with what we have written. Also, some of our critics rightly observe that parental involvement in pediatric decision making raises complicated questions, and we welcome to the opportunity to address the complexities they identify. Finally, Katz and Webb (2017) accuse us of systematically misreading the AAP documents they helped to author, and of reaching troubling conclusions about the ethics of pediatric decision making. We conclude with a detailed response to their objections.

The Ethics of Vaccination Nudges in Pediatric Practice.

Techniques from behavioral economics—nudges—may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges.

Privacy and Religious Exemptions

Religious exemptions policies raise issues of personal information privacy. If applicants for religious exemptions must demonstrate that the laws to which they object impose special burdens on them, then there is a good reason to require applicants to disclose the religious convictions that lead them to object. But how much personal information privacy is it reasonable for the state to violate in order to assess applications for religious exemptions? In some cases, very little personal information—perhaps amounting only to the fact of one’s denominational membership—may be necessary for representatives of the state to determine whether someone objects for a religious reason. Privacy violations seem justified in these cases of effective minimal mandated disclosure. However, in many cases no amount of mandated personal information disclosure will enable representatives of the state to determine whether an objector has a religious objection. Privacy violations are unlikely to be justified when they do not result in disclosure of the kind of information necessary to assess whether objectors have religious objections.

Rawls on Inequality, Social Segregation and Democracy

Latent in John Rawls’s discussion of envy, resentment and voluntary social segregation is a plausible (partial) explanation of two striking features of contemporary American life: (1) widespread complacency about inequality and (2) decreased political participation, especially by the least advantaged members of society.

How Demanding is the Duty of Assistance

Among Anglo-American philosophers, contemporary debates about global economic justice have often focused upon John Rawls’s Law of Peoples. While critics and advocates of this work disagree about its merits, there is wide agreement that, if today’s wealthiest societies acted in accordance with Rawls’s Duty of Assistance, there would be far less global poverty. I am skeptical of this claim. On my view, the Duty of Assistance is unlikely to require the kinds and amounts of assistance that would be sufficient to eradicate much global poverty. This is because the DA cannot require societies to rapidly or radically change their ways life, and because the kinds and amounts of assistance that are most likely to eradicate global poverty would cause rapid and radical changes to the ways of life of the societies that undertook them.