Christian Scientist scenario

[exodus]

Restraining was just an example of the kind of force that may be considered. In this case it may be that you wouldn't have to use much force, perhaps just initiating care and ignoring the parent's protests, or removing the child to the ambulance. But if it gets physical I'm not adverse to protecting myself and the patient. This is a more drastic scenario, but letting a potentially dying child just lay there isn't an option.

1. Call for code 3 law enforcement (and possibly an extra ambulance and a fire crew if there isn't one present)
2. Quickly try to reason with the parents (probably less than a minute)
3. Get access to the patient - if that means getting them out of there, great, and if the parents try to block you, then get them out of the way. Stop only if there's a serious risk to yourself.

Have fun in prison. My livelihood is not worth it.

Edit: And what charges?

Assault & Battery, kidnapping, kidnapping with force, false imprisonment. I'm sure the DA can find more. It's not YOUR child. It's their child. They have the right to choose what treatment the child gets.

 

[Brevi]

Granted this scenario is a bit extreme, but so are a lot of the responses here. You don't need to get a refusal and walk away, but you don't need to fight anyone either.

The Medical Director should be able to take the child into protective custody sight unseen.

I'll talk to DCF and try to get some answers specific to this type of scenario for ya'll.

 

[exodus]

Granted this scenario is a bit extreme, but so are a lot of the responses here. You don't need to get a refusal and walk away, but you don't need to fight anyone either.

The Medical Director should be able to take the child into protective custody sight unseen.

I'll talk to DCF and try to get some answers specific to this type of scenario for ya'll.

Why would they take the child into protective custody? If there's no abuse, there is nothing wrong.

 

[Brevi]

Why would they take the child into protective custody? If there's no abuse, there is nothing wrong.

A physician has the legal authority to take temporary protective custody of a child without the consent of the parents or caretaker if certain conditions are met, such as refusing life saving treatments. A parent can not refuse treatment in a life threatening situation, even if for religious reasons.

And it's definitely a form of abuse. It may not be as obvious to some as beating or starving a child, but it is certainly abuse.

 

[Brevi]

Ask one of your ER docs the procedure they would use to take PC in your area.

 

[exodus]

A physician has the legal authority to take temporary protective custody of a child without the consent of the parents or caretaker if certain conditions are met, such as refusing life saving treatments. A parent can not refuse treatment in a life threatening situation, even if for religious reasons.

And it's definitely a form of abuse. It may not be as obvious to some as beating or starving a child, but it is certainly abuse.

Cite this please.

 

[VFlutter]

Did you read any of the information that was posted? This isn't a novel idea I cooked up....it's been established by common law, written law, and the courts. This is also a concept that a healthcare professional should have some familiarity with.....

Ya, Did you? All of those case studies except one took place outside the United States. They also all involved court orders prior to treatments. It is different circumstances then the original scenario.

Can MDs and hospitals get court orders to force treatment on minors when parents refuse treatment? Yes. Do they forcibly provide treatment and physically remove parents? No. Especially without a court order or ethics committee involvement.

I am not advocating just sitting around and letting kids die however I am against the fanatical mentality of "I am treating that kid and no one can stop, if those parents get in my way I will physically restrain them, etc". Take the emotion out of it. You may not have the medical or legal authority to make those decisions.

Call me heartless but I am not risking my career and livelihood for a patient, even a child. I didn't sacrifice 4+ years of school and assume 10s of thousands of debt to throw it away. And I will sleep just fine at night.

 

[Brevi]

google parental autonomy doctrine

 

[fortsmithman]

I would pull back at that point and stage a block from the scene and call for police and child welfare to go to the scene. The moment they arrive I would go back in. Because in all probability the child welfare officer would apprehend the child under the child welfare act. Once that happens we would be able to attempt treatment.

 

[TheLocalMedic]

Have fun in prison. My livelihood is not worth it.

Edit: And what charges?

Assault & Battery, kidnapping, kidnapping with force, false imprisonment. I'm sure the DA can find more. It's not YOUR child. It's their child. They have the right to choose what treatment the child gets.

So if that kid collapsed and isn't breathing you would walk away just because the parents say so? The parents in that case may be committing negligent homicide. Are you saying that if you saw someone strangling a woman on the street you'd walk away because, God forbid, trying to help her might somehow get you a battery charge?

In this case, the parents do not have the right to withhold care. If it's something non-lifethreatening, that's a different story.

Here's some great quotes from the Sullivan Group regarding patient AMA rights:

"Generally, state and federal courts support parental control over the basic matters affecting their children. However, when parental actions have resulted in inadequate medical care, courts in the United States have stepped in to decide between parent wishes and physician concerns. Under the doctrine of "parens patriae" (the state's paternalistic interest in children) the state will not allow a child's health to be seriously jeopardized because of the parent's limitations or convictions. A parent does not have the authority to forbid saving their child's life. Courts invariably rule in favor of a physician who claims that a parent is denying standard medical care to a child. One judge asserted that "The right to practice religion freely does not include the liberty to expose... a child... to ill health or death. Parents may be free to become martyrs themselves. But it does not follow that they are free ... to make martyrs of their children…"

"The parents will typically stand down and allow you to proceed with your mission."

"If there is no life threat, and no potential for serious impairment, the parent’s AMA request should be respected. "

"Remember that you are protected from civil and criminal liability under the child abuse and neglect statutes. You may be hesitant to take custody, but it should not be for fear of liability."

 

[jrm818]

All of those case studies except one took place outside the United States.

Not Quite, I posted 4 links, the first from the American Academy of Pediatrics speaking to US law, the next two from Canada and England because they did a good job of laying out the ethical issues (and in once case do reference the Massachusetts Prince case), and one from North Carolina illustrating some state specific issues.


They also all involved court orders prior to treatments. It is different circumstances then the original scenario.

Emergencies are very different from situations allowing for time to obtain court orders, and that has historically been understood by the courts. For example, from texas: (though it concerns withholding care due to disabilities rather than religious beliefs) : http://virtualmentor.ama-assn.org/2003/08/hlaw1-0308.html

Can MDs and hospitals get court orders to force treatment on minors when parents refuse treatment? Yes. Do they forcibly provide treatment and physically remove parents? No. Especially without a court order or ethics committee involvement.

Not accurate. See Above. That may be the way it tends to work on a hospital floor with conditions that don't need treatment immediately, but in an emergency situation it should be obvious to anyone that there is not time to obtain a court order or convene the ethics committee, and in this case treatment should begin parallel to LE, the courts, etc. becoming involved. It is a well established legal principle that emergencies are treated differently in all sorts of ways.

You don't have to believe my ramblings. Here's the guidance from the American Academy of Pediatrics, posted earlier....luckily they've written a position paper on just this issue - specific to emergencies and even to prehospital care.



"A particularly challenging situation occurs
when the health care professional
is faced with a legal guardian
who refuses to give permission for
treatment of a child in situations in
which such treatment is considered
essential to the child’s well-being.
[...]parental permission
is required before the evaluation and
treatment of a child. Parental authority
is not absolute, however, and when a
parental decision places a child at significant
risk or serious harm compared
with an alternative decision, the
state may intervene to require intervention
over the objections of the legal
decision-maker.
As long as a child’s legal guardian possesses
medical decision-making capacity,
he or she has the right to refuse
medical care for the child. However,
the guardian is required to act in the
best interest of the child. When a legal
guardian refuses to consent to medical
care or transport that is necessary

and likely to prevent death, disability,
or serious harm to the child, law enforcement
officers may intervene under
local and state child abuse and neglect
laws. It is always preferable to
negotiate with the legal decisionmaker
and attempt to achieve an
agreeable plan for safely managing
the child’s medical condition.
When faced with a guardian who refuses
to allow the provision of necessary
medical care or transport of a
child when it is necessary to save a
child’s life or prevent serious harm, it
might be necessary to notify the police
and enlist their assistance in placing
the child in temporary protective custody.
In a life-threatening emergency, it
might be necessary to involve hospital
security so that emergent evaluation
and treatment can begin while child
protective services and the police are
notified. Likewise, when a legal guardian
appears to be intoxicated or otherwise
impaired, involvement of law enforcement
officers might be necessary
to place a minor in temporary protective
custody.[...] Under these
circumstances, a medical professional
should provide medical treatment
without consent only when the child
has a medical condition that poses a
risk of death or serious harm, when
immediate treatment is necessary to
prevent that harm, and when only
those treatments necessary to prevent
the harm are provided.25"


They even wrote a bit for EMS:

"If at all possible, an assessment
should be performed to determine
if there is a medical emergency,
and medical consultation should be
sought if the emergency medical technicians
are unclear about whether a
threat to life or limb exists. If parents
are present or accessible and refuse
care for their injured or ill child, they
must be informed of the risk of not
transporting a sick or injured pediatric
patient, which might include death
or permanent disability. Regardless of
religious beliefs or parental desires,
every attempt should be made to treat
and/or transport a child with a lifethreatening
emergency or if providers
suspect child abuse. EMS providers
should involve medical control early in
these situations and use law enforcement
resources as necessary to ensure
that the patient receives the necessary
emergency stabilization and
transport."



I am not advocating just sitting around and letting kids die however I am against the fanatical mentality of "I am treating that kid and no one can stop, if those parents get in my way I will physically restrain them, etc". Take the emotion out of it. You may not have the medical or legal authority to make those decisions.

In an emergency with no other resources immediately available I feel fairly confident that you do. What evidence do you have suggesting the opposite?


Call me heartless but I am not risking my career and livelihood for a patient, even a child. I didn't sacrifice 4+ years of school and assume 10s of thousands of debt to throw it away. And I will sleep just fine at night.

I disagree that loosing a job or being incarcerated is at all a likely outcome of treating over parental objections, and I'd love to see a single example where something similar happened. Similarly, obeying parental wishes carries risks - and honestly legal problems seem much more likely to occur due to an untreated dead child than over a scorned religious zealot. I admit I have no evidence for that particular claim.

Mine in blue

General comment: I am genuinely curious where everyone is getting the idea that parents can refuse lifesaving care in an emergent situation. Not one shred of outside evidence has been posted supporting this notion. The medical ethics books I've seen say the opposite. Googling returns the opposite answer. Were you taught this in school? Is this just your general impression of how the American legal system works? Does anyone with relevant qualifications agree with you (serious question, not snark)?

 

[Rialaigh]

No clue where you wanted us to look on that website, but as to the top of the post: my understanding is that the laws you reference protect parents from criminal charges for failing to obtain medical care for their children. Those laws do not prohibit medical personnel from overruling paretns to provide life saving care in an emergency

That's a mighty fine line to walk. Several of those laws specifically state that parents are legally covered from charges for refusing treatment for their child even in life saving circumstances. Hospitals with ethics boards and committees of doctors respect these parents wishes and their child's. why shouldn't EMS

 

[Jim37F]

My protocol basically says call the cops in this situation

Department of Health Services
County of Los Angeles
Reference No. 832 Treatment/Transportation of Minors
I. C. If Prehospital care personnel believe a parent or other legal representative of a minor is making a decision which appears to be endangering the health and welfare of the minor by refusing indicated immediate care or transport, law enforcement authorities should be involved.

So if I show up on a scene and the parents refuse care due to religious reasons, my first reaction would be to tell them "If you don't let me treat them, I will be forced to call the police. Please, let's keep that can of worms closed and just let me do my job and save your childs life".

If they relent, great, proceed to treat as normal. If not, get on the radio and request LEOs respond emergent.

While waiting for them to arrive, continue negotiating with the parents. I'm thinking something along the lines of "Look, I resect your religious beliefs, but please respect mine. I cannot simply just watch a child die and do nothing about it, especially if I have the tools to stop it. If you truly believe that God is calling your child to heaven right now then nothing I will do will matter anyway, so please, just let me try. Because if on the other hand it's NOT their time, we can prevent such a devastating loss to your family". Etc.

If they relent, great, initiate treatment/transport. If not, wait for LEOs. Once they arrive they'll either a)do what they need to to detain the parents and allow you to do your job. In that case, forget about the parents and treat/transport the kid as their condition indicates.
I'll definitely be filling out a suspected child abuse form at this point. Otherwise that's the end of my involvement, let the state send people far more familiar with the intricacies of the law investigate.

Option b) is if the LEOs for whatever reason tell you no, you can't treat, the parents are within their rights to refuse treatment. After I'm through looking at said cop like he's got a d*** growing out of his forehead, I'd request supervisors from both your agency and the LE agency code 3 to the scene. If that ruling still stands, well, it'd suck royally, make me want to puke, but I'd no more initiate treatment than I would for a patient with a valid DNR.

But somehow I just don't see option B being the more likely scenario.

 

[medicsb]

Hospitals with ethics boards and committees of doctors respect these parents wishes and their child's. why shouldn't EMS

Where are you getting your information from? In emergent situations it is not uncommon for physicians to have parents removed from the ED in order to care for a child against the objections of the parents. In less emergent conditions, hospital and physicians can and do petition the court system for an order to provide care (e.g. cancer treatment). It may not be an everyday occurrence, but it does happen.

 

[TheLocalMedic]

That's a mighty fine line to walk. Several of those laws specifically state that parents are legally covered from charges for refusing treatment for their child even in life saving circumstances. Hospitals with ethics boards and committees of doctors respect these parents wishes and their child's. why shouldn't EMS

I'm not sure why you believe this.

"Natalie Rippberger, eight months, died December 9, 1984 in Santa Rosa, California, of h-flu meningitis. The parents, Mark and Susan Rippberger, had retained a Christian Science practitioner for spiritual "treatment" but would not get essential medical care for their daughter… Natalie's parents, Mark and Susan Rippberger, were charged with felony child endangerment and involuntary manslaughter. Both were convicted of felony child endangerment."

"Shauntay Walker, age four, died March 8, 1984, in Sacramento, California, of h-flu meningitis. Shauntay was home sick from her pre-school for 17 days. She received no medical care, only Christian Science "care." …. Laurie Walker was charged with involuntary manslaughter, and on June 21, 1990, over six years after her daughter's death, she pled guilty to that charge"

"Amy Hermanson, age seven, died September 30, 1986, in Sarasota, Florida, of untreated juvenile onset diabetes. Her parents refused to provide her with necessary medical care…. Amy's parents were charged with felony child abuse and third degree murder. Both were convicte on the charge of third degree murder."

"Loren Willliamson, age five, died June 1989, of lymphocytic leukemia in Loranger, Louisiana. Annetta Williamson, the mother, belongs to the Church of God; she prayed for divine healing instead of obtaining medical care….The mother was booked for negligent homicide."

"Robyn Twitchell, age two, died in April, 1986, in Boston, Massachusetts, of a bowel obstruction. A simple operation to remove the twisting of the bowel would have most likely saved Robyn's life….In July, 1990, the Twitchells were convicted of manslaughter."

"Elizabeth Ashley King, age 12, died June 5, 1988, in Phoenix, Arizona, of bone cancer. She was out of school and sick at home from November 1987 to May 1988….Ashley told nurses and doctors: "I'm in so much pain...You don't know how I've suffered."…The parents, John and Catherine King, pleaded no contest to the felony of reckless endangerment in their daughter's death."

"Lisa Sheridan, age five, died in 1967 in Cape Cod, Massachusetts, after a three week battle with pneumonia without medical care. Lisa received Christian Science prayer treatment over the entire course of her illness. Lisa's mother was tried and convicted of involuntary manslaughter."

"Justin Barnhart, age two, died September 1981, in Beaver Valley, Pennsyslvania of a Wilm's tumor which grew larger than a volleyball in the child's abdomen. The parents, William and Linda Barnhart, withheld medical care from their son because of their religious beliefs. With early medical intervention, this form of childhood cancer has a better than 90 percent cure rate. The parents were convicted of involuntary manslaughter in 1982 by the county court. Although Pennsylvania had a religious exemption law in the code dealing with reporting of child abuse and neglect, the prosecution successfully argued that he law did not apply to criminal charges. In September 1988, the United States Supreme Court voted 9-0 against reviewing the state conviction of the parents."

And there are many many more...

 

[MonkeyArrow]

I'd like to cite the Dennis Lindberg case:
http://www.pediatricethics.org/news/noteworthy-stories/dennis-lindberg/
as evidence that the courts have held in certain situations that potentially life saving medical care can be withheld from minors leading to their deaths due to religious beliefs. I do understand that this case is not exactly the same as aforementioned scenario in this thread and that there are significant legal differences. However, there are also some similarities which could also be legally decisive.

Namely, a difference between this thread's scenario and the Lindberg case is that the boy was refusing treatment on his own behalf. His parents were actually urging him to get the treatment for which he refused. The judge basically declared that Dennis Lindberg has the right to refuse treatment as an emancipated minor and was thus mature enough to understand the consequences of not attaining the treatment he needed to survive. Even though the minor wanted to refuse treatment, he was still under the legal care of his aunt, an adult, until the judge ruled him an emancipated minor.

However, the precedent that this case sets may also be legally significant. The judge allowed a minor to die by refusing to seek medical care, something in which some of you have refused to say would let happen. However, the courts found in favor of letting Lindberg refuse treatment as a minor and die. Additionally, we must think what happens when the minor is not given an independent status as was given in this case. At that point, the minor is still under the care of the parents/legal guardian and the medical decision is their's to make. Since the judge allowed said minor to withhold treatment and die, you must assume that legal precedent MAY have been set and other minors could follow down the same path. If one minor is allowed to withhold treatment, why can't the other one's too (since the decision was/is being made by the appropriate legal entity)? How can you make a determination that the child wants to receive the treatment that is being forced upon him. Akin to this case, the minor may be old enough to understand and comprehend but not old enough to make legal decisions to withhold treatment. How does one get the legal power to remove a family member from life support? How is one tasked with the responsibility and legally allowed to choose when someone dies (legally is a whole different beast than real life. yes, the person is already brain dead in real life but legally still alive)?

 

[jrm818]

I'd like to cite the Dennis Lindberg case:
http://www.pediatricethics.org/news/noteworthy-stories/dennis-lindberg/
as evidence that the courts have held in certain situations that potentially life saving medical care can be withheld from minors leading to their deaths due to religious beliefs. I do understand that this case is not exactly the same as aforementioned scenario in this thread and that there are significant legal differences. However, there are also some similarities which could also be legally decisive.

Namely, a difference between this thread's scenario and the Lindberg case is that the boy was refusing treatment on his own behalf. His parents were actually urging him to get the treatment for which he refused. The judge basically declared that Dennis Lindberg has the right to refuse treatment as an emancipated minor and was thus mature enough to understand the consequences of not attaining the treatment he needed to survive. Even though the minor wanted to refuse treatment, he was still under the legal care of his aunt, an adult, until the judge ruled him an emancipated minor.

However, the precedent that this case sets may also be legally significant. The judge allowed a minor to die by refusing to seek medical care, something in which some of you have refused to say would let happen. However, the courts found in favor of letting Lindberg refuse treatment as a minor and die. Additionally, we must think what happens when the minor is not given an independent status as was given in this case. At that point, the minor is still under the care of the parents/legal guardian and the medical decision is their's to make. Since the judge allowed said minor to withhold treatment and die, you must assume that legal precedent MAY have been set and other minors could follow down the same path. If one minor is allowed to withhold treatment, why can't the other one's too (since the decision was/is being made by the appropriate legal entity)? How can you make a determination that the child wants to receive the treatment that is being forced upon him. Akin to this case, the minor may be old enough to understand and comprehend but not old enough to make legal decisions to withhold treatment. How does one get the legal power to remove a family member from life support? How is one tasked with the responsibility and legally allowed to choose when someone dies (legally is a whole different beast than real life. yes, the person is already brain dead in real life but legally still alive)?

so the argument is that since a court emancipated a conscious 14 year old based on his ability to articulate the implications of his decision regarding a non-emergent treatment;therefore a parent in a seconds-urgent situation can make the decision for their child to withhold life saving care, despite the fact that the child is unconscious, totally unable to participate in the decision, uninformed, possibly not mature enough to understand the implications of the decisions were he even conscious, and not able to voice any objections to his parents religion?

Come on - I refuse to believe you don't realize that those are so completely different as to make the case you posted totally irrelevant (never mind the much more on point references already posted establishing parental non-omnipotence).

It is already well established that an adult or emancipated minor can refuse their own care for any reason they want, provided their refusal is fully informed (just like informed consent). The case you posted establishes that a 14 year old can be emancipated. I would have spotted you that without the case in front of me. The case has nothing to do with parental wishes -it's about individual autonomy not parental authority!

Similarly, the scenario in the OP has nothing to do with decisions about life support withdrawal in a non-acute situation, conscious patients able to participate in their own decisions, DNR's for terminal conditions, emancipation, etc.

 

[MonkeyArrow]

so the argument is that since a court emancipated a conscious 14 year old based on his ability to articulate the implications of his decision regarding a non-emergent treatment;therefore a parent in a seconds-urgent situation can make the decision for their child to withhold life saving care, despite the fact that the child is unconscious, totally unable to participate in the decision, uninformed, possibly not mature enough to understand the implications of the decisions were he even conscious, and not able to voice any objections to his parents religion?

Come on - I refuse to believe you don't realize that those are so completely different as to make the case you posted totally irrelevant (never mind the much more on point references already posted establishing parental non-omnipotence).

It is already well established that an adult or emancipated minor can refuse their own care for any reason they want, provided their refusal is fully informed (just like informed consent). The case you posted establishes that a 14 year old can be emancipated. I would have spotted you that without the case in front of me. The case has nothing to do with parental wishes -it's about individual autonomy not parental authority!

Similarly, the scenario in the OP has nothing to do with decisions about life support withdrawal in a non-acute situation, conscious patients able to participate in their own decisions, DNR's for terminal conditions, emancipation, etc.

What I'm saying is that the legal entity in charge of making the decision can…well… make the decision. In this case, the legal entity was the emancipated minor, and he was thus allowed to refuse treatment for a condition that was life-threatening (he died something like 14 hours after the ruling). Therefore, since justice is theoretically blind, any legal entity should theoretically be able to make that call to withhold treatment whether the parents have legal powers or the minor through emancipation. For the record, I did devote a whole paragraph to how this wasn't OP's scenarios and how it is different but potentially relatable.

 

[jrm818]

What I'm saying is that the legal entity in charge of making the decision can…well… make the decision. In this case, the legal entity was the emancipated minor, and he was thus allowed to refuse treatment for a condition that was life-threatening (he died something like 14 hours after the ruling). Therefore, since justice is theoretically blind, any legal entity should theoretically be able to make that call to withhold treatment whether the parents have legal powers or the minor through emancipation. For the record, I did devote a whole paragraph to how this wasn't OP's scenarios and how it is different but potentially relatable.

You are committing a logical error: you assume that parental authority is legally indecipherable from either individual autonomy or authority vested in another person e.g. by a durable power of attorney. This is false. Parental authority does not convey the same decision making power that individual autonomy does, it is more limited. This is not just my opinion - it is the general opinion of ethicists and the courts. See all the evidence above.

It's a concept that makes sense. Children have not yet had the opportunity to make informed, well reasoned decisions about their priorities, beliefs, and wishes. Our society has held that these children have the right to grow up safely until such time as they can make these decision on their own.




and just an FYI: even authority vested by a power of attorney, another situation where legal authority to make decisions rests in someone other than the patient, is limited. The holder of the legal authority has a fiduciary responsibility to the patient (meaning they have to act in the patient's best interest, not their own interests). The same is true of parents. Courts do overrule POA's occasionally if the agent is not acting in the best interest of the patient.

 

[MonkeyArrow]

You are committing a logical error: you assume that parental authority is legally indecipherable from either individual autonomy or authority vested in another person e.g. by a durable power of attorney. This is false. Parental authority does not convey the same decision making power that individual autonomy does, it is more limited. This is not just my opinion - it is the general opinion of ethicists and the courts. See all the evidence above.

It's a concept that makes sense. Children have not yet had the opportunity to make informed, well reasoned decisions about their priorities, beliefs, and wishes. Our society has held that these children have the right to grow up safely until such time as they can make these decision on their own.




and just an FYI: even authority vested by a power of attorney, another situation where legal authority to make decisions rests in someone other than the patient, is limited. The holder of the legal authority has a fiduciary responsibility to the patient (meaning they have to act in the patient's best interest, not their own interests). The same is true of parents. Courts do overrule POA's occasionally if the agent is not acting in the best interest of the patient.

I understand where you're coming from. Each person has the right to life, liberty, and the pursuit of happiness and thus children must be ensured that legally until they are mature enough to do it for themselves (which is also the argument for allowing/banning abortion). I guess that the issue now becomes even if there is a general consensus, we still see a lot of these cases going before judges and ethics panels. Therefore, relating back to OP's scenario, would it all fall in place fast enough to save a minor in pediatric arrest? I don't think so.