# Ethics: Parents Refusing Treatment for Children



## MMiz (May 31, 2010)

What would you do if you were at the scene of a serious trauma and the patient's parent/guardian refuses medical treatment for their minor?

I'm in that situation, of sorts, and am conflicted on my path forward.


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## firecoins (May 31, 2010)

MMiz said:


> What would you do if you were at the scene of a serious trauma and the patient's parent/guardian refuses medical treatment for their minor?
> 
> I'm in that situation, of sorts, and am conflicted on my path forward.



how do you know its the parent?  

tell the cops whats up.  Could be criminal actions to refuse treatment in such a situation.


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## medic417 (May 31, 2010)

Are they refusing all treatment or only one treatment?


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## MMiz (May 31, 2010)

What if the parent refused treatment for a minor injury?


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## MMiz (May 31, 2010)

medic417 said:


> Are they refusing all treatment or only one treatment?


Great question, and from what I gather it matters.  I don't know at this point, and most likely I'll never know.  Unfortunately this is a hypothetical situation that stemmed from something complete unrelated to EMS.


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## medic417 (May 31, 2010)

MMiz said:


> Great question, and from what I gather it matters.  I don't know at this point, and most likely I'll never know.  Unfortunately this is a hypothetical situation that stemmed from something complete unrelated to EMS.



It is a fine line legally.  If it is a minor illness, injury I doubt any legal authority would remove the parents rights to refuse care.  If it is a serious illness or injury possibly a court would rule against the parents if they were refusing all care.  If they only refuse one procedure and there are other options the courts normally still side with the parents even when Doctors feel the alternatives are not as good.


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## MidwestFF (May 31, 2010)

At least locally for all but the most minor injuries all it would take is the opinion of 2 public safety providers IE: 1 FF and 1 PD or 1 FF and 1 EMT etc that the care is reasonably required and they can take custody of the child in order to render aid then transfer the child's care to social services. If the injury is imminently hazardous to life and limb all it takes is one, but you will have a lot of explaining to do.

I have seen this explained to a reluctant parent once; they consented although begrudgingly so as not to have Child Protective Services involved.


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## medic417 (May 31, 2010)

MidwestFF said:


> At least locally for all but the most minor injuries all it would take is the opinion of 2 public safety providers IE: 1 FF and 1 PD or 1 FF and 1 EMT etc that the care is reasonably required and they can take custody of the child in order to render aid then transfer the child's care to social services. If the injury is imminently hazardous to life and limb all it takes is one, but you will have a lot of explaining to do.
> 
> I have seen this explained to a reluctant parent once; they consented although begrudgingly so as not to have Child Protective Services involved.



Wow can any one say law suit?  I would own your community if my child had care I refused forced on them.  Sorry If I were you I would only use that protocol as a very last resort for something very extreme.  There are some very complex legal issues at play and based on your post I am afraid your service has not fully explored all of them.


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## lightsandsirens5 (May 31, 2010)

I'd say number one, make sure they are the parent. 

If they were still refusing treatment after you trying to talk them into letting you provide care, call the cops.


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## JPINFV (May 31, 2010)

MidwestFF said:


> At least locally for all but the most minor injuries all it would take is the opinion of 2 public safety providers IE: 1 FF and 1 PD or 1 FF and 1 EMT etc




Assuming that the FF and LEOs aren't medical providers (EMTs or above, and to be fair, I'm tempted to exclude all of EMS since there's too much of "ZOMG, everything is life threatening and everyone injured will die in the next 2 minutes if not treated with everything" in the training), who are they to see what is or is not reasonable medical care?


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## Fox800 (May 31, 2010)

In my system, parents are not allowed to refuse treatment for their children who present with life-threatening illnesses or injuries.


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## medic417 (May 31, 2010)

Fox800 said:


> In my system, parents are not allowed to refuse treatment for their children who present with life-threatening illnesses or injuries.



Ka-ching.  Man I see dollar signs in some parents future.


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## Fox800 (May 31, 2010)

medic417 said:


> Ka-ching.  Man I see dollar signs in some parents future.



Hasn't been a problem yet. This is in a major metropolitan area.


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## FLEMTP (May 31, 2010)

medic417 said:


> Ka-ching.  Man I see dollar signs in some parents future.




You keep saying this... over and over.. sue sue sue lawsuit ... 

can you provide any sort of a legal precedence that would suggest that a lawsuit would even have legal standing in a situation as described in the original post? or are you just spouting off because you live in fear of a lawyer and litigation?


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## firecoins (May 31, 2010)

If a child has a life threatening injury, we will transport with or with out parents permission.  Parent can refuse in the ED with the doctor.  Let them sue me. I am more than happy to treat and transport first and let the lawyers figure it out afterwards than let the kid die and have it be my fault.  

Anything less than life threatening, parent can do what they want.


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## medic417 (May 31, 2010)

FLEMTP said:


> You keep saying this... over and over.. sue sue sue lawsuit ...
> 
> can you provide any sort of a legal precedence that would suggest that a lawsuit would even have legal standing in a situation as described in the original post? or are you just spouting off because you live in fear of a lawyer and litigation?



I have seen first hand the results of medics that have ignored parents.  No I do not live in fear.  No I will not present the cases, they are easily found.


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## firecoins (May 31, 2010)

medic417 said:


> I have seen first hand the results of medics that have ignored parents.  No I do not live in fear.  No I will not present the cases, they are easily found.


Why put foward the argument if you won't back it up? If they are easily found, you would present them.


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## Eydawn (Jun 1, 2010)

This is indeed a hell of a grey zone. My personal feeling would be that you could only overrule parents if it is something that is obviously life-threatening (AKA: the FF/LEO also sees that the kid is actually in danger of dying). 

If I were presented with this kind of situation, I would turf it to medical control and local law enforcement. I would also try persuading the parents as strongly as possible that their child is in imminent danger of death or permanent disability. If it is obvious that the care is being withheld as a form of abuse, it should be fairly easy to hold up your actions in court, especially if you've got LEO and an order from an MD to back you up. 

Use judiciously. Do not over-use. Be veeery careful with how you approach the situation. Document the hell out of whatever decision you and your med control and your LEO end up making, whether you provide care or not. 

I would agree that I would err on the side of letting the lawyers figure it out after I've taken care of the kid... a minor child (or compromised adult for that matter) is depending on the good judgment of the parent and if that judgment is obviously lacking, I'd say we have an ethical responsibility to the child. 

Wendy
CO EMT-B


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## MonkeySquasher (Jun 1, 2010)

firecoins said:


> If a child has a life threatening injury, we will transport with or with out parents permission.  Parent can refuse in the ED with the doctor.  Let them sue me. I am more than happy to treat and transport first and let the lawyers figure it out afterwards than let the kid die and have it be my fault.
> 
> Anything less than life threatening, parent can do what they want.




You'll be happy to know that, I believe, per NYS DOH you may treat a ped with life/limb threatening injury/illness regardless of parental consent.  "Action is preferable to inaction".  Call PD to override parental consent, or call OLMC to override parental consent (which may require PD, not sure).

And as always, document document document.  haha


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## Akulahawk (Jun 1, 2010)

Fox800 said:


> In my system, parents are not allowed to refuse treatment for their children who present with life-threatening illnesses or injuries.





medic417 said:


> Ka-ching.  Man I see dollar signs in some parents future.


Not to mention Ka-ching if the child presents with life-threatening injury or illness, the parents refuse care and the provider does nothing...

That's a situation where you're you can get sued for doing something or doing nothing.

Here, I'd call LE, explain the situation, and if the LEO agrees, there are several ways that could go, but they all result in the child being treated.


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## FLEMTP (Jun 1, 2010)

medic417 said:


> I have seen first hand the results of medics that have ignored parents.  No I do not live in fear.  No I will not present the cases, they are easily found.



you know.. just for the hell of it.. I did a google search using the search terms "paramedic child parents lawsuit" and in 10 pages of search results.. I could not find a single link to any story of an EMS provider being sued for taking a pediatric patient against the parents wishes...so I'm curious.. are you using a different search engine? 

Or is it entirely possible that the cases are not as "easily found" as you claim them to be, because you simply have nothing to back up your claim that this happens quite frequently?


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## medic417 (Jun 1, 2010)

I owe everyone an apology as the cases do not show up.  Sorry guys.  I even pulled up by name some of the cases I am aware of in multiple states and found some of the incidents such as a wreck but there is no information about the law suits.  So as I call people out for no evidence I have been called out and have lost.  All I can presume is that because minors were involved and cases were settled no details were released.  My bad I will eat crow now.


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## medic417 (Jun 1, 2010)




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## got_shoes (Jun 1, 2010)

The First Amendment to the US Constitution prohibits any action by an American government which restricts "the free exercise of religion." Now as far as case law, I believe that if it has to do with minor children, there won't be a lot of information dealing with this subject. I would say most if these local laws potentially violates the first amendment in certain cases.(read NOT ALL) Most EMS providers need to be careful when dealing with parents and their rights and responsibility with their children. Some providers may consider this a form of child abuse and would be reported to respective child protection services.

"Problems sometimes occur in cases involving a minor or other person who is incapable of giving informed consent for their own treatment. Parents and guardians are generally given almost complete freedom in providing or denying health care to their children. But, in the case of life-threatening medical conditions, the courts and Child Protective Services have occasionally intruded, and ordered treatment of a child against the wishes of its parent(s)."


"Religious exemptions in child abuse laws:

In 1974, the U.S. Department of Health, Education and Welfare first required states to have clauses in their child abuse and neglect legislation that permits exemptions from prosecution of parents on religious grounds. If a state refused, they would not receive federal child abuse protection grants.

In 1983, the federal government allowed states to repeal these clauses. However, most state still allow parents to use a religious defense if their child dies because prayer was used instead of medical treatment.

Some recent activity at the state level:

	1994 Oregon: Legislature committees heard testimony on two House bills that would require all parents to obtain medical help for their seriously sick or injured children. The bills had strong backing from both major parties, law enforcement, physicians, social workers and child advocates. "...there was limited testimony from Christian Scientists who warned that eliminating the so-called spiritual defense from Oregon's homicide statutes and other areas of the law would unfairly impose upon their religious rights." 4  The House later endorsed a compromise faith healing bill that allows defendants to claim faith healing as a defense.

	1994 Minnesota: The state passed a law which requires parents or guardians to alert child protection services if they have withheld medical treatment and that their children were endangered by their decision. Few if any parents or guardians report under this law.

	1998 Texas: Critical-care pediatrician Seth Asser said:
"Kids die from accidental deployment of air bags, and you get hearings in Congress. But this goes on, and dozens die and people think there's no problem because the deaths happen one at a time. But the kids who die suffer horribly. This is Jonestown in slow motion."

The American Medical Association, the National District Attorneys Association, the Academy of American Pediatrics and a growing number of local and state legislators agree with him. 

	2001: The Academy of American Pediatrics went on record in opposition to these exemption laws. 5

Colorado as well as Oregon had experienced an increase in juvenile death rates that paralleled the growth of anti-medical faith groups. 5  Amanda Bates, 13, suffered a horrendous, lingering and painful death from diabetes and gangrene in early 2001. She and her family attended the General Assembly and Church of the First Born. She was the third child to die in that church in three years. This motivated legislators to eliminate an exemption from the child abuse law that had  protected parents from abuse charges if they withheld medical attention from children.

	2002: 38 states had laws that shield parents from persecution if they reject medical treatment for their children in favor of faith healing. However, most of these state laws specify that if a child's condition is life-threatening, then a physician must be consulted. 6

	2009: Rita Swan is the executive director of the Iowa based Children’s Health Care Is a Legal Duty. They advocate charging parents who do not seek medical help when their children need it. She reports that about 300 children have died in the United States during the previous 25 years after medical care was withheld on religious grounds. 

Child abuse laws in 30 states still provide some form of protection for practitioners of faith healing in cases of child neglect and other matters. 1
Some state laws exempt parents only if their children are faced with a non-life threatening condition or disease. The Oregon law covering criminally negligent homicide requires that the prosecution prove that the defendant failed to be aware of a substantial and unjustifiable risk that is "a gross deviation" from what a reasonable person would observe in a similar situation. 7 Both are difficult to prove in court. Parents can claim that they did not realize that their child's condition was very serious; they can claim lack of medical knowledge. A British law requires parents to seek medical help for their children, if the child's condition does not improve after 72 hours of non-medical treatment. That type of legislation may be more effective." source:http://www.religioustolerance.org/medical1.htm


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## EMSLaw (Jun 1, 2010)

Don't seek easy answers to complex questions.  This isn't a simple one - and I'm a lawyer.  Using Google to try and ponder this out is like thinking you know as much as a doctor because you can pull up WebMD and enter your symptoms.

Sitting on the side of the street with an injured kid is not the time to argue over the legal nicities of the situation.  Personally, I would involve the police, or summon them if they weren't already there, explain the situation, my take on the kid's condition, and let them take the heat if we were ordered to treat.  

Hospitals have lawyers on staff for this and other reasons.  The matter can be worked out through whatever part of your court system is involved in guardianship actions (I've been involved in a few, as counsel).  My feeling on the matter is that you should do your best to act reasonably, and in the best interests of the child (and your patient).  But I would recommend against taking things into your own hands, unless it really is a life-threatning emergency in which there are only minutes between life and death.  In that rare situation (and how often is it *really* the case?), and this is personal, and not legal advice, I would err on the side of life, and let them hash it out later.


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## got_shoes (Jun 1, 2010)

The US Supreme Court ruled on this in 1905 biggest difference is this is for public health issues e.g. vaccination programs. and not for protection of a minor child in need of medical care/ treatment. Parents have been allowed to refuse care for their children based on the parents believing prayer or herbal therapies are believed to be superior to modern medicine most courts including the supreme court have up held these decisions by lower courts.


*Although the right to reproduce is considered a fundamental right which cannot be
abridged by government unless there is a sufficiently narrowly tailored remedy serving a
compelling state interest, the same cannot be said of parental rights. Parents can lose their rights to maintain custody, and decision-making capacity, for their children in a wider array of circumstances. In the medical arena this can occur when medical issues
affecting a child’s life arise.*


Legal precedent and authority currently exists for a state to intervene when an individual
parent’s refusal to seek medical treatment for a child threatens the general public.
Without question, for some diseases and some therapies parental refusals to allow their
child to be medicated not only dramatically increases the likelihood of the child getting
the disease,5 but also greatly increases the health risks to other children they may come
into contact with.
For example, the government’s ability to implement mandatory vaccination programs
(e.g. for measles, polio, tetanus) is based on the 1905 United States Supreme Court ruling
in Jacobson v. Massachusetts.6 The case addressed the issue of whether it was
constitutional for a state to require mandatory smallpox vaccinations.7 The Court held
that the states were justified in enacting mandatory vaccination programs based on the inherent state police power to protect its citizens’ public health, safety, and welfare.
The Supreme Court revisited the Jacobson issue again in 1922 in Zucht v.
King10 when a group of parents claimed a constitutional right to refuse vaccinations for
their children. The Court rejected the parents’ claims, and extended the original ruling in
Jacobson to hold that school and public health officials could decide the manner and
types of mandatory vaccinations.11 Specifically, the Court found that “these [public
vaccination] ordinances confer not arbitrary power, but only broad discretion required for
the protection of public health.”

*There are only a few cases in which parents have been charged, or threatened to be
charged, with criminal conduct for refusing to allow their child to be treated for a
potentially life-threatening medical conditions, *and there is no clear consensus on the
way in which prosecutors, judges, and juries shall deal with these difficult situations at
the intersection of medical ethics and family law. *There are currently no clearly-defined limits for when a parent’s choices not to seek medical care for a child is deemed
negligent.*
The facts and circumstances involved in the cases vary greatly – and these differences
may ultimately be the deciding factors in determining the outcome of each case. The
ages of the children in question differ as do their educational levels and the degree to
which they likely understand the nature of their ailment, the therapy being denied, or all
of the health implications of the denial of such therapy. There is also a great difference
in the diseases the children possess. Some children have benign diseases, but potentially
life-threatening if effective therapy is denied.


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## atropine (Jun 1, 2010)

First off at the very least I would get my supervisor in on it, as well as the er Doc, and then go from there.


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## MidwestFF (Jun 1, 2010)

Now as some discussed we are waiting on a lawsuit, as with anything it depends on your local laws. To my knowledge this has been used more along the lines of child needing treatment and parent nowhere to be found. This is not a pleasant process by any stretch of the imagination that requires tons and tons of paperwork to be filled out. It is used as a absolute last resort. To my knowledge at least in our organization it has never been used to directly overrule a parent. Has there been some proverbial arm twisting, yes. Outright overruling a parent no.

The one case I had mentioned before, parent and minor occupant had been in a high speed head on collision both had suffered head trauma. Parent  definitely had a altered level of conciseness, the child was critical and unconscious; we had to suction teeth(yes this is plural) and blood just to get an airway in the child. We wanted to do this the right way but we where going to do what we had to either way. The altered parent was convinced and gave consent for the minor. I know that the parents LOC opened up a whole new can of worms in regards to the actual consent. After more than a week the parent contacted our service to say thanks for doing what was right and provide care to them and their child. They even admitted to not being in their right mind at the time.

The procedure is meant for these kinds of circumstances to cover us when we are forced to do the right thing for all involved. We would not even think of using this route for something minor we would just report our observations to the appropriate authorities CPS and LEO.


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## mycrofft (Jun 2, 2010)

*1905 case law.*

At that time children (and women, for that matter) had severely constricted civil rights. If a foetus can be murdered through intentional maternal drug and alcohol abuse or homocide of the mother to be, then a real living kid must have some sort of rights in that vein.
And as for lawsuits...you try to save a life, it distresses the parents, they will get over it or sue you. The child is your patient and there your duty lies.

Sometimes you're handed the hot poker, and no matter which end, to hold it you will get burned.


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## got_shoes (Jun 2, 2010)

Mycroft the case law from 1905, was more for public health, due to highly infectious disease, the government at the time believed they had a higher responsibility to the masses rather then a few who didnt want to have vaccinations. the problem with your lawsuits idea is that more then likely civil rights are being violated, and i would say most EMS providers do not want to get wrapped up on civil rights case. To me it would make sense to use the LEO's along with my medical director maybe have him/her talk to the parent


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## mycrofft (Jun 2, 2010)

*Sure..........*

And don't get me started on people who won't immunize their kids or themselves, or urban people who won't license and neuter their pets*.

If the kid is gravely disabled and was expected to die soon, is incapable and will be incapable of making a decision, then you may have the equivalent of a DNR.

If the kid is going down solely because the parent has religous issues, or is inebriated, or is afraid of Immigration or Child Protective Services or the Probation Dept or an estranged spouse's lawyer or just cannot make up their mind, let 'em go. You might not get sued. Feel good about that.


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## firecoins (Jun 2, 2010)

If a child is dying from a chronic illness and has a DNR, I would listen to the parents.  

As for the religion of the parents.  Under what situation will I find a dying kid and still be on scene to find out the parents don't believe in modern medicine?


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## LucidResq (Jun 2, 2010)

You should cite your sources, otherwise it appears you are presenting it as your own original thought or research. 

The following passages came verbatim from this article, authored by B Patsner of the Health Law & Policy Institute of the University of Houston Law Center. 



got_shoes said:


> *Although the right to reproduce is considered a fundamental right which cannot be
> abridged by government unless there is a sufficiently narrowly tailored remedy serving a
> compelling state interest, the same cannot be said of parental rights. Parents can lose their rights to maintain custody, and decision-making capacity, for their children in a wider array of circumstances. In the medical arena this can occur when medical issues
> affecting a child’s life arise.*





got_shoes said:


> Legal precedent and authority currently exists for a state to intervene when an individual
> parent’s refusal to seek medical treatment for a child threatens the general public.
> Without question, for some diseases and some therapies parental refusals to allow their
> child to be medicated not only dramatically increases the likelihood of the child getting
> ...





got_shoes said:


> The Supreme Court revisited the Jacobson issue again in 1922 in Zucht v.
> King10 when a group of parents claimed a constitutional right to refuse vaccinations for
> their children. The Court rejected the parents’ claims, and extended the original ruling in
> Jacobson to hold that school and public health officials could decide the manner and
> ...





got_shoes said:


> *There are only a few cases in which parents have been charged, or threatened to be
> charged, with criminal conduct for refusing to allow their child to be treated for a
> potentially life-threatening medical conditions, *and there is no clear consensus on the
> way in which prosecutors, judges, and juries shall deal with these difficult situations at
> ...


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## got_shoes (Jun 2, 2010)

lucid, I meant to post a source, got side tracked. but it does happen all the time,not that, that makes it okay in any way. None of the things I posted were from me. but at the same time, before pointing the finger at me, you might want to look at you signature....same holds true for that


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## LucidResq (Jun 2, 2010)

got_shoes said:


> lucid, I meant to post a source, got side tracked. but it does happen all the time,not that, that makes it okay in any way. None of the things I posted were from me. but at the same time, before pointing the finger at me, you might want to look at you signature....same holds true for that



Ha, fair enough. There is a big difference between academia and entertainment though.


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## Veneficus (Jun 2, 2010)

Choosing the battles.

(I just got back to internet access can you tell?) 

Anyway, I have seen 2 instances where parents were refusing care for a child. One for a 14 y/o female with an arterial bleed from putting a hand through the window the parents were really concerned they couldn't pay. One from a femur fx at some weird no medicine religious group where the mom called 911 and asked to treat/transport and the father was refusing.

In the first instance, some kind explanations of just how serious this was sufficed to get permission. (other options involving LE were not needed)

In the second case, when the father started dragging the kid off the cot, a bunch of cops pounced on him and charged him with abuse. The charges were later dropped, but he was arrested long enough for mom to give the go to us and all the folks at the hospital.

How the marriage went after that is anyone's guess. I have no idea.

A few states I am familiar with have laws for life threatening conditions, but long and short. If you think the injury is not apparent and immediately life threatening or reasonably become so, why fight it?

Document all that happened especially that you explained in lay person terms why you thought the pt should go to the hospital, encourage the parents to call 911 or go to the ED if something changes, have everyone sign, i always like an LEO as a witness, and call it a day.

Not every cut that could be helped by sutures will get them.

One occult injury that I really press the case on are potential scaphoid fx. Usually resulting from a fall on an outstretched hand. (FOOSH) It does not appear on xray and the complication is debilitating avascular necrosis of the wrist and hand. The injury is treated as if it is fractured, and dx is confirmed by bone remodeling that shows up on xray in a few weeks followup.


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## firecoins (Jun 2, 2010)

LucidResq said:


> Ha, fair enough. There is a big difference between academia and entertainment though.



thats a matter of opinion.


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## got_shoes (Jun 3, 2010)

there can be a difference between the two....sometimes. I should have posted the source, so on that my bad, but this has been a very interesting discussion none the less.


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