The Child's Best Interest: Ethical Guide or Ideology? | John Lantos & Bernard Dan | DMCN

Bernard Dan

I am Bernard Dan, Editor-in-Chief of Developmental Medicine and Child Neurology. I recently wrote an editorial on the child's best interest. In this editorial, I raised a number of ethical questions for clinical practice. Today, I'm having a conversation on this topic with Dr. John Lentos, who has been a leading and inspiring expert on bioethics. Hi, John.

Dr. John Lantos

Hi, how are you?

Bernard Dan

Fine. It's great to have you. I would like to ask you how you see the child's best interest in medical practice.

Dr. John Lantos

The goal is to keep doctors and in the worst case scenarios eventually courts and judges focused on the child and the child's interests rather than the interests of all the adults who are involved in decision making. The conflicts come up when what's best for the child is either uncertain or is in conflict with what's best for some of the adults.

Bernard Dan

You can then determine what the child's best interest is.

Dr. John Lantos

Most of the time, even in really difficult circumstances, doctors and parents sit down and consider all the issues and come to an agreement, and the tough cases are the ones where, for whatever reason, doctors and parents can't agree, and there the question becomes one of whether some objective assessment of what's best for the child, some outside assessment ought to prevail, or whether parents by default simply because their parents ought to be able to make the decision. I think that in those cases, the best interest standard or principle, whatever you want to call it, the focus on the child's best interest helps us because it orients everybody towards thinking about what's best for the child.

Bernard Dan

Are there some factors that can help us categorize situations to address issues with more clarity? The age of the child, for example, has been suggested by some to be important in this regard.

Dr. John Lantos

There's some evidence that people are much more likely to provide medical treatment for older children than they are for either newborns or particularly for extremely premature babies. People have an idea of personhood or belonging to the human community that they apply to older children, but not to premature babies to the same degree.

Bernard Dan

Doesn't this contradict general ethical thinking?

Dr. John Lantos

I think it does. Again, the principle of best interest would dictate that we focus on what's best for the child. The principle

Bernard Dan

of

Dr. John Lantos

justice would suggest that children with equal prognoses should be treated equally.

Bernard Dan

How can we address disability or the risk for disability when discussing the child's best interest?

Dr. John Lantos

One of the issues that comes up frequently is a question of whether the mere possibility of future disability should dictate that treatment be withheld or withdrawn.

Bernard Dan

Do you think it's relevant to make a distinction between anticipated disability and quality of life?

Dr. John Lantos

Quality of life, to my mind, is a very subjective judgment. So I think it's important to separate those subjective ratings of quality of life from objective measures of disability. So that, for example, somebody who's confined to a wheelchair might say, I hate being confined to a wheelchair. I really wish I could walk. My life would be better if I could walk. But my quality of life, given that I'm in wheelchair, is very good. I have good relationships. I enjoy various activities. I'm glad to be alive.

Bernard Dan

One more question, John. Do you think this approach is universal and can be applied across cultures?

Dr. John Lantos

I think it is peculiarly Western and relatively modern. I think the more... traditional approach to such decisions is and has been to view the family as the locus of moral concern and the best interests of the family as the guiding principle. In many cultures, it's not parents per se, but fathers who have the responsibility and the legal right to consider what's best for the family and their decisions are binding. I think the idea that children have rights independent of their parents or family is a relatively new and predominantly Western view, although I think it is taking root in other parts of the world today.

Bernard Dan

Well, thank you very much, John, for sharing these threads with us.

Dr. John Lantos

Okay.