Pediatrics, Volume 57, Issue 3: Pages 414-416, March 1976.
Note:
This file contains the former, now outmoded, guidance of the American Academy of Pediatrics regarding informed consent. The document still contains some sound advice. This document is presented for historical purposes, so readers may better understand the previous position of the Academy and so that the progression in ethical thought is made clearer. This position has now been substantially modified and superseded by a newer document, one written in the light of the Convention on the Rights of the Child (1989), and more recent legal decisions on limitations of parental rights. For the current position of the AAP regarding informed consent, see Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 95(2):314-317.
Task Force on Pediatric Research, Informed Consent, and Medical Ethics.
CONSENT
Rowine H. Brown, M. D., author for the Task Force.
A long-established legal principle holds that a person has a right not to have his body touched by another. If a physician touches any part of the patient's body with or without instruments during treatment - without authority - he may be prosecuted criminally or sued for damages in a civil action. Court decisions to this effect go back beyond the present century. Historically, the law has always required specific consent by the patient to all operative procedures. The greater the potential risk, the greater the duty of the physician to inform the patient concerning them, so the patient can decide which risks he wants to assume. The patient makes the final decision about whether to take a chance with the treatment or operationrecommended by the physician or risk the consequences.
Generalities concerning consent are difficult to define when the involved patients are infants or minors, who may be incompetent and are not legally empowered, without guardian consent, to make serious decisions regarding their bodies. In such instances, the parent, next of kin, or guardian is legally required to give consent. The physician should also be aware of the ever increasing numbers of state statutes which empower some classes of minors - or minors in some specific situations- to give their consent.
INFORMED CONSENT
One rapidly changing and expanding law which is currently inflicting a massive impact on medical professional liability is informed consent. Approximately ten years ago, the Supreme Court of the State of Kansas in one of its opinions coined the phrase informed consent, which is a facet of the newly discovered basic human right termed the right to know. The patient must now be given an opportunity to be informed of matters which are relevant to the care he is about to receive. This means explanation of risks, alterative procedures, and other related matters, including the benefits to be derived and the hazards to be endured if the patient refuses to undergo the recommended treatment. The pediatrician now has a duty to explain to patients and parents the nature and risks of procedures which he feels are essential to the health and welfare of the child. He should make an entry on the medical record that such an explanation was made, and how the child (if old enough to understand) and the parent responded.
Informed consent is a rule of law which adds another legal burden to the practice of medicine and as such results in more exposure to liability. Because the doctrine of informed consent is of recent origin, guidelines have not yet been developed by court decisions or by statute, but, they are slowly evolving andshould be reported in medical media.
Recommendations for the protection of human subjects are being considered by the Department of Health, Education, and Welfare. Its proposed guidelines recommend that no research be conducted without informed consent, and that consent committees be developed to monitor this requirement.
Consent forms have been developed and are use in many private offices and hospitals. When a multitude of specific forms have been devised, searching for the correct form and getting it properly signed and witnessed may become burdensome and outside the realistic function of the physician. Regardless of any inconvenience or annoyance, the correct consent form must be obtained. Titling a form informed consent form and having it signed and even witnessed, does not always indicate to he judge and/or jury that informed consent was actually obtained. Signatures on such a document may carry little weight when the significance of the document is challenged in court. Therefore, a dated entry on the medicalrecord is good defensive evidence.
MINORS
As a general rule, treatment of a minor requires the consent of the parent or guardian, except in an emergency when effective treatment is imperative and delay would involve serious risk to the life or limb of the patient. In such an emergency situation, a minor may usually give his own consent. The rule of thumb in applying for parental consent is the feasibility of obtaining such consent, weighed against the necessity of urgent treatment for the child. The physician is the sole judge of this. Documentation about the state of the emergency must be available; and the physician should enter appropriate justification on the medical record. A concurring opinion by a second physician would be beneficial.
Minors in need of treatment who are married, pregnant, or emancipated (which here means living on their won) may give valid consent for their medical or surgical care under some statutes. These minors may also consent to treatment for their children.
Some courts have held that a minor's consent is sufficient if he is mature enough to understand the full significance of the contemplated treatment. Age is not always a true criterion of maturity or intelligence. There seems to be no sound justification for denying a minor who is mature enough to comprehend the nature and consequences of the procedure the right to accept or reject treatment. Court rulings have permitted minors of mature judgment to give their consent to therapy, even for nonemergency conditions including nose-bobbing and removal of disfiguring lesions (such as those of Von Recklinghausen's disease).
STATUTORY LAW REGARDING MINORS
In recent years many statutes have been enacted in which the rights of minors to treatment on their consent have been specified. This trend will continue. For example, the legislatures in 25 states have enacted specific statutes which permit minors over the age of 12 years to give consent for treatment of venereal disease and/or drug abuse. Notification to their parents is not required. By statutory provisions, at least 40 other states now permit medical examination and medical treatment of certain categories of minors without parental consent. In addition, 11 states have broadened the rights of minors and allow them to give consent to obtain contraceptive services without parental consent. These last-mentioned court decisions and statutes demonstrate the judicial and legislative trends toward freeing understanding minors to obtain medical assistance on their own and allowing physicians to provide assistance without fear of a possible malpractice action because of lack of consent. These court rulings and legislative acts also demonstrate the flexibility of the law makers when there is a specific goal, such as eradication of venereal disease or drugabuse.
Considering the diversity of statutory law in the various states, the paucity of appellate and supreme court decisions, and rapidly evolving local changes, a reasonable safeguard for physicians in all elective cases would be to get written consent for surgery or treatment from any minor 13 years of age or older in addition to that of the parent.
It is suggested that consent to research procedures should be obtained from all children over the age of 7 years (the earliest age the law considers that a child could form a specific intent). It is also wise to include a provision that the procedure will be verbally explained to the minor and his wishes respected. His consent form may assure the parent that a study not specifically essential to the child will be discontinued if the child exhibits fear or resistance.
No reported legal cases indicate that consent of both parents is required prior to treating a minor. If a controversy exists between the parents relative to the treatment, the physician should attempt to secure the consent of both. When the parents are separated or divorced, the physician should obtain the consent of the parent with the legal custody, or one in loco parentis (acting as parent).
CONCLUSION
Consent must be obtained prior to the institution of medical or surgical treatment. Pediatricians should be kept informed concerning court decisions and statutes relative to consent and minors.
TASK FORCE ON PEDIATRIC RESEARCH, INFORMED CONSENT AND MEDICAL ETHICS
HORACE L. HODES, M.D. Chairman (1974-1975)
VICTOR C. VAUGHAN, III M.D. Chairman (1975-1976)
CHARLES A. ALFORD, Jr. M.D.
ROWINE HAYES BROWN, M.D.
MALCOLM A. HOLLIDAY, M.D. (1974-1975)
AVRUM L. KATCHER, M.D.
CALVIN C. J. SIA, M.D.
DAVID SPARLING, M.D. (1974-1975)
Consultants
LEWIS A. BARNESS, M.D.
L. STANLEY JAMES, M.D.
SAMUEL L. KATZ, M.D.
SUMMER J. YAFFE, M.D.
Task Force on Pediatric Research, Informed Consent, and Medical Ethics. Consent. Pediatrics 1976;57(3):414-7.
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