AAP: Religious objections to medical care

THE PROBLEM

The American Academy of Pediatrics (AAP) recognizes that religion plays a major role in the lives of many children and adults in the United States and is aware that some in the United States believe prayer and other spiritual practices can substitute for medical treatment of ill or injured children. Through legislative activity at the federal and state levels, some religious groups have sought, and in many cases attained, government recognition in the form of approved payment for this nonmedical therapy and exemption from child abuse and neglect laws when children do not receive needed medical care. The AAP opposes such payments and exemptions as harmful to children and advocates that children, regardless of parental religious beliefs, deserve effective medical treatment when such treatment is likely toprevent substantial harm or suffering or death.

The US Constitution requires that government not interfere with religious practices or endorse particular religions. However, these constitutional principles do not stand alone and may, at times, conflict with the independent government interest in protecting children.¹ Government obligation arises from that interest when parental religious practices subject minor children to possible loss of life or to substantial risk of harm.^2,3 Constitutional guarantees of freedom of religion do not permit children to be harmed through religious practices, nor do they allow religion to be a valid legal defense when an individual harms or neglects a child.⁴

Acute Illness or Injury

The AAP asserts that every child should have the opportunity to grow and develop free from preventable illness or injury.⁵ Children also have the right to appropriate medical evaluation when it is likely that a serious illness, injury, or other medical condition endangers their lives or threatens substantial harm or suffering. Under these circumstances, parents and other guardians have a responsibility to seek medical treatment, regardless of their religious beliefs and preferences. Unfortunately, certain groups have obtained exemptions from legal sanctions and state child abuse and neglect reporting laws based on the child's treatment by spiritual means, such as prayer.⁶ The overall effect has been to limit the government's ability to protect children from abuse or neglect.

The AAP is concerned about religious doctrines that urge parents to avoid seeking medical help when there children are seriously ill. Each year, some parents' religious views lead them to eschew appropriate medical care for their children, resulting in substantial harm or suffering or death due to treatable conditions such as meningitis, bowel obstruction, diabetes mellitis, or pneumonia (Boston Globe August 12, 1993:1; Pittsburg Post-Gazette, March 16, 1991:B1).^4,7 The AAP considers failure to seek medical care in such cases to be child neglect, regardless of the motivation. The basic moral principle of justice requires that children be protected uniformly by laws and regulations at the local, state, and federal levels. Parents and others who deny a child necessary medical care on religious grounds should not be exempt from civil or criminal action that otherwise would be appropriate. State legislatures and regulatory agencies should remove religious exemption clauses from statutes and regulations to ensure that all parents understand that they should seek appropriate medical care for their children.

Preventative Care

Some religious tenets hold that members should not seek or receive medical care for any condition, including pregnancy. These beliefs can result in increased perinatal and maternal mortality.⁸ Some religious groups deny children the benefits of routine preventative care. For example, some parents, acting in accord with state laws, refuse to have their children immunized because of religious beliefs. The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations. Although the risk to unimmunized individuals is relatively low, serious adverse reactions to vaccination are rare and the AAP strongly endorses universal immunization. Recent outbreaks of vaccine preventable infectious diseases, with consequent serious complications and deaths, have been linked to groups that refused immunization for religious reasons.^9-12

The AAP therefore supports the use of appropriate public health measures, such as mandatory mass vaccinations in epidemic situations, when necessary to protect communities and their unimmunized members. In addition, the AAP is concerned that children unimmunized for any reason may expose young children not old enough to be protected, to infections such as pertussis or invasive Haemophilus influenzae disease. The risk is especially high in child care facilities. In such situations, all parents of children in the facility should be informed of the hazards.

Mature Minors

The weight given to parental beliefs in decisions affecting their children's well-being declines with the child's increasing age and development. That is, as minors mature, their interest in and capacity for participating in health care decisions affecting themselves increases, as does their ability to make decisions regarding their parents' religious views. The law and AAP policy recognize the doctrine of the mature minor.¹³ This concept acknowledges that many children beginning in adolescence, can contribute to or make medical decisions, including those about life- sustaining treatment. Thus, in selected cases, disputes may be avoided when a minor has the capacity to make an independent decision in light of religious values and recommended medical therapy.

Need for Care and Respect

The AAP wishes to underscore its recognition of the important role of religion in the personal, spiritual, and social lives of many individuals and cautions physicians and other health care professionals to avoid unnecessary polarization when conflict over religious practices arises. Pediatricians should seek to make collaborative decisions with families whenever possible and should take great care when considering authority to override parental preferences. Nevertheless, physicians who believe that parental religious convictions interfere with appropriate medical care that is likely to prevent substantial harm or suffering or death should request court authorization to override parental authority or, under circumstances involving an imminent threat to a child's life, intervene over parental objections. When caring for children whose prognoses are grave even with treatment, physicians should use restraint in pursuing a court order to initiate or continue treatment when parents object to it. In such situations, physicians should work with the parents and children to assure appropriate palliative care. Threatening or seeking state intervention should be the last resort, undertaken only when treatment is likely to prevent substantial harm or death. Even under those circumstances, physicians should respect parental religious beliefs and the role of parents in rearing their children. Of course, a physician may withdraw from these cases after securing acceptable alternative medical care, when continuing in the doctor-patient-family relationship would violate the physicians's own moral precepts.

The AAP emphasizes that all children who need medical care that is likely to prevent substantial harm or suffering or death should receive that treatment. The AAP opposes religious doctrines that advocate opposition to health care for sick children. Adherence to such views precludes appropriate assessment and intervention to protect the children. The AAP believes that laws should not encourage of tolerate parental activity that prevent implementing appropriate medical treatment, nor should laws exempt parents from criminal or civil liability in the name of religion.

RECOMMENDATIONS

The AAP calls for all those entrusted with the care of children to:

1. show sensitivity to and flexibility toward the religious beliefs and practices of families;
2. support legislation that ensures that all parents who deny their children medical care likely to prevent death or substantial harm or suffering are held legally accountable;
3. support the repeal of religious exemption laws; and
4. work with other child advocacy organizations and agencies and religious institutions to develop coordinated and concerted public and professional action to educate state officials, health care professionals, and the public about parents' legal obligations to obtain and necessary healthmedical care for their children.

COMMITTEE ON BIOETHICS, 1995 TO 1996
Joel E. Frader, MD, Chairperson
Lucy S. Crain, MD
Katheryn L. Moseley, MD
Robert M. Nelson, MD
Ian H. Porter, MD

LIASON REPRESENTATIVES
Watson Bowes, MD
American College of Obstetricians & Gynecologists
Alexandra Kazura, MD
American Academy of Child & Adolescent Psychiatry
Earnest F. Krug, III, MD
American Board of Pediatrics

SECTION LIASON
Donna A. Caniano, MD, Section on Surgery

LEGAL CONSULTANT
Nancy M. P. King, JD

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Pediatrics 1997 PEDIATRICS (ISSN 0031 4005). © Copyright 1997 by the American Academy of Pediatrics.

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