Balancing protection and respect in paediatrics

The clinical care of children can pose dramatic ethical and legal challenges for clinicians and parents. Some of these difficulties can best be summed up by a phrase familiar to every mischievous child and exasperated adult: “Grow up!” We want children to be as adult as they can and yet we do not want them to be more adult than they should. In their clinical contact with children, doctors are no different. They want children to cooperate as fully as possible in their care and support. Sometimes, however, children may be reluctant to do so, posing perplexing dilemmas for everyone concerned.

To see why, consider one of the things that makes the unexpected death of any child so tragic: the thought of the lost potential that this represents. For this young person there will be no challenges posed and met, no formation of lasting adult relationships and, most importantly, no chance of the emergence and exploration of a unique and evolving identity. They go to the grave, in the words of the American author Henry Thoreau, “with their song still in them”.1 Such tragedy underlines the moral importance of providing children with such opportunities to flourish and doing our best to respect their evolving autonomy. While parents can play the most important role in achieving this, the responsibility extends to all those whose contact with children may influence the formation of their future character. Paediatricians obviously fit this bill.

Yet we may face a paradox when providing such encouragement. With greater freedom to explore and experiment comes greater risks of harm and distress. Such exploration entails seeking new experiences in unfamiliar circumstances—through adventure, success and failure—and potentially harmful mistakes and misjudgements are an ever-present possibility. The trick is to minimise the harm without pretending that it can be entirely …