Judge rules family can't refuse chemo for boy

[Danbo1957]

MINNEAPOLIS -- (AP) A Minnesota judge ruled Friday that a 13-year-old cancer patient must be evaluated by a doctor to determine if the boy would benefit from restarting chemotherapy over his parents' objections.

In a 58-page ruling, Brown County District Judge John Rodenberg found that Daniel Hauser has been "medically neglected" by his parents, Colleen and Anthony Hauser, and was in need of child protection services.

While he allowed Daniel to stay with his parents, the judge gave the Hausers until Tuesday to get an updated chest X-ray for their son and select an oncologist.

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http://www.msnbc.msn.com/id/30763438

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[cpants]

Parents have the right to make choices for their kids based on religious beliefs, but only to a point. When their choice has a 90% chance of death associated with it, not so much.

 

[Miami_med]

The whole concept of informed consent implies that a patient has the right to refuse treatment. In the case of a minor who wishes to refuse treatment, we force his parents to make the decision, because he isn't old enough to understand the consequences of his action. His choices may not make sense to most of us, but I'm not fond of the idea that if you make an informed choice with which we disagree, someone gets to go change your mind. This also isn't like refusing bacitracin on a dirty cut or a vaccine without which other people might be impacted (though we let people refuse those all the time). Chemotherapy has very real and very severe side effects that are virtually omnipresent in patients, some of which have very real permanent sequelae.

There is a subjective component to all of these decisions, regardless of the chance of death. If the parents didn't seem to want to do what they thought was best for the child or were refusing treatment over his objection, I think the argument for intervention is stronger. The parents seem to be trying to do what they think is best for him (even though we disagree). It simply isn't our decision to make.

 

[Pharmavixen]

That's a thoughtful take, MM. Though I personally didn't find much of a controversy here when there's a near-certain death sentence without tx, and a very good chance of recovery with tx, and he's young enough that we can presume (a little uneasily) that he can't decide for himself.

But what if he were 16 instead of 13, and the prognosis was poorer? Then maybe what would happen is the courts would get involved, and a private family tragedy would get turned into a public spectacle, and ultimately, no-one would win but the lawyers.

 

[ThinkTooMuch]

what does the boy want? Thats all that ought to matter.

 

[Instatewaiter]

I have to say that while I completely disagree with the stance of the family, this court decision really makes me uneasy. The fact that the boy cannot read and probably cannot consent doesn't make it much less disconcerting that the court felt it had the right to force treatment. It is a hop skip and a jump away from direct paternalism. No sir I dont like it.

 

[Quix]

It's parens patriae - the court has a vested interest in the well-being of third parties (like the incapacitated and children), which gives the state the right to order care (even against parents wishes). Once the kid is 18 and capable of offering or refusing consent, he's free to do as he wishes. Until then, not so much.

 

[cpants]

The whole concept of informed consent implies that a patient has the right to refuse treatment. In the case of a minor who wishes to refuse treatment, we force his parents to make the decision, because he isn't old enough to understand the consequences of his action. His choices may not make sense to most of us, but I'm not fond of the idea that if you make an informed choice with which we disagree, someone gets to go change your mind. This also isn't like refusing bacitracin on a dirty cut or a vaccine without which other people might be impacted (though we let people refuse those all the time). Chemotherapy has very real and very severe side effects that are virtually omnipresent in patients, some of which have very real permanent sequelae.

There is a subjective component to all of these decisions, regardless of the chance of death. If the parents didn't seem to want to do what they thought was best for the child or were refusing treatment over his objection, I think the argument for intervention is stronger. The parents seem to be trying to do what they think is best for him (even though we disagree). It simply isn't our decision to make.

While I agree with you that it is a bit unnerving to have the government intervene in a parental decision, it really is necessary in some cases. Being a parent doesn't give you carte blanche to do whatever you want with your kid, even if your religion commands it. For example, we do not allow 13 year old girls to be forced into "marriages", which is a part of the teachings of certain fundamentalist mormon sects. We don't allow this even though the parents truly believe this is the best thing for their child.

If you are making decisions which put your kid at high risk of death, you are showing poor enough judgment that we need to intervene. Keep in mind, I'm not saying all parents should be forced to go along with the doctor's recommendations in all cases. I agree with you that some parents might opt against chemotherapy justifiably if the circumstances were different. This stuff has to be taken case by case.

I know it is a slippery slope, but really anything is a slippery slope to some degree. Responsible use of this power by the courts is both necessary and desireable for protection of the children's rights.

 

[facetguy]

In this case, the oncology opinion was that treatment has a 90% chance of curing the boy. Would anyone's opinion change if the chance was estimated to be, say, 70%? Or 50%? As we all know, cancer treatments are not guaranteed success stories...far from it. And as Miami Med reminds us, such treatments are usually associated with serious side effects. So where's the line in terms of risk/reward level in these cases?

 

[NonTradMed]

Being a parent doesn't give you carte blanche to do whatever you want with your kid, even if your religion commands it. For example, we do not allow 13 year old girls to be forced into "marriages", which is a part of the teachings of certain fundamentalist mormon sects. We don't allow this even though the parents truly believe this is the best thing for their child.

And that, I think, is a good analogy to this case. Just because a parent believes they are doing right for their child does not mean it is in the best interest of the child. We can't assume that every decision made with care by the parent is actually good for the child.

In this case, the oncology opinion was that treatment has a 90% chance of curing the boy. Would anyone's opinion change if the chance was estimated to be, say, 70%? Or 50%? As we all know, cancer treatments are not guaranteed success stories...far from it. And as Miami Med reminds us, such treatments are usually associated with serious side effects. So where's the line in terms of risk/reward level in these cases?

I guess this is where medical opinion will matter more. In medicine, there are many cases where there may be no clear cut line. I think a case by case basis must be made. There are no easy decisions.

 

[vicca]

He can't make decisions for himself, so giving that power to parents who are obviously not fit and endangering the child's life seems like the wrong call to me.

 

[facetguy]

He can't make decisions for himself, so giving that power to parents who are obviously not fit and endangering the child's life seems like the wrong call to me.

In this case, given the '90% cure' opinion, it seems fairly straightforward. But at what % are the parents no longer endangering the child's life by foregoing treatment? At what point do the dangers of the treatment itself endanger the child more?

 

[cpants]

In this case, given the '90% cure' opinion, it seems fairly straightforward. But at what % are the parents no longer endangering the child's life by foregoing treatment? At what point do the dangers of the treatment itself endanger the child more?

For this scenario to even get to the courts, the doctor has to think the parents are making a decision which will significantly harm the child. Once there, the judge will have to decide based on both sides' arguments if the parents are actually breaching their duty. For the most part, we have to err on the side of the parents' judgment.

Of course as the treatment gets more invasive and less life-saving, the parents' case gets stronger and stronger. However, we should resist attempts to put an acceptable % survival for parents to go against doctors' advice. These numbers involve a lot of guesswork, and each child's case will have intricacies and complications which will make it difficult to determine and apply survival odds. The courts should continue to decide these case by case, as they have been doing for a long time, by the way. This certainly isn't the first time this has happened, and in fact, it is the procedure you are taught to follow in medical school. It's even tested on the boards.

 

[facetguy]

For this scenario to even get to the courts, the doctor has to think the parents are making a decision which will significantly harm the child. Once there, the judge will have to decide based on both sides' arguments if the parents are actually breaching their duty. For the most part, we have to err on the side of the parents' judgment.

Of course as the treatment gets more invasive and less life-saving, the parents' case gets stronger and stronger. However, we should resist attempts to put an acceptable % survival for parents to go against doctors' advice. These numbers involve a lot of guesswork, and each child's case will have intricacies and complications which will make it difficult to determine and apply survival odds. The courts should continue to decide these case by case, as they have been doing for a long time, by the way. This certainly isn't the first time this has happened, and in fact, it is the procedure you are taught to follow in medical school. It's even tested on the boards.

Agreed. By asking for a percentage, I'm not advocating that there should be a hard-and-fast number by which all cases are to be decided. I'm just pointing out that a medical opinion is just that, an opinion, and that there is often likely to be a lot of gray involved.

 

[tibor75]

I wonder if this would even go to trial if the kid's parents didn't have insurance.

"We refuse this treatment"

"sure, since you have no insurance, I won't get paid anyway"

 

[Miami_med]

While I agree with you that it is a bit unnerving to have the government intervene in a parental decision, it really is necessary in some cases. Being a parent doesn't give you carte blanche to do whatever you want with your kid, even if your religion commands it. For example, we do not allow 13 year old girls to be forced into "marriages", which is a part of the teachings of certain fundamentalist mormon sects. We don't allow this even though the parents truly believe this is the best thing for their child.

If you are making decisions which put your kid at high risk of death, you are showing poor enough judgment that we need to intervene. Keep in mind, I'm not saying all parents should be forced to go along with the doctor's recommendations in all cases. I agree with you that some parents might opt against chemotherapy justifiably if the circumstances were different. This stuff has to be taken case by case.

I know it is a slippery slope, but really anything is a slippery slope to some degree. Responsible use of this power by the courts is both necessary and desireable for protection of the children's rights.

Then who decides what requires intervention? You. The people making these decisions are also known for repeatedly showing poor judgement. In what way is this violating the child's rights? He doesn't want the treatment either? You are saying that the government and the medical establishment have decided to supplant their judgement for that of both this individual and his parents. At the very least, this is one case in which the doctor and hospital and all providers involved should have to eat the cost of treatment, because it is certainly wrong to force people to buy things with which they disagree on a fundamental level. You can also believe that the next time any kid within this religious group actually gets sick, the child will be brought nowhere near the doctor's office. People distrust the medical establishment to this day, and this is why.

 

[cpants]

Then who decides what requires intervention? You. The people making these decisions are also known for repeatedly showing poor judgement. In what way is this violating the child's rights? He doesn't want the treatment either? You are saying that the government and the medical establishment have decided to supplant their judgement for that of both this individual and his parents. At the very least, this is one case in which the doctor and hospital and all providers involved should have to eat the cost of treatment, because it is certainly wrong to force people to buy things with which they disagree on a fundamental level. You can also believe that the next time any kid within this religious group actually gets sick, the child will be brought nowhere near the doctor's office. People distrust the medical establishment to this day, and this is why.

So do you believe that a Jehovah's Witness parent should be able to refuse a transfusion for their exsanguinating child after a car accident? This case is really an extension of that scenario over a longer time period. In general, parents should have rights to decide what care their child does or does not receive. We may not agree with their decision, but it usually does not warrant any legal intervention on our part. When the parents' decision is basically a death sentence for the child, we need to act.

Would your opinion change if the child did want the treatment and was begging to be saved, but the parents would not consent? It shouldn't. The child is by law unable to make this decision and unable to understand its consequences. That does not mean a child has no rights. It is part of our duty as physicians to make sure those rights, including a right to life, are protected.

 

[Pharmavixen]

In the 1960s, my mother (nurse, now ret.) recalls giving blood to Jehovah's Witnesses. They'd hang the bag of blood behind the pt's head, and arrange the tubing to be as inconspicuous as possible.

Guess that's why they call them "the good old days."

 

[cpants]

I wonder if this would even go to trial if the kid's parents didn't have insurance.

"We refuse this treatment"

"sure, since you have no insurance, I won't get paid anyway"

Very cynical.

 

[seelee]

Very cynical.

right, I was wondering when someone was going to accuse the doctor of only being interested in money.

 

[Miami_med]

So do you believe that a Jehovah's Witness parent should be able to refuse a transfusion for their exsanguinating child after a car accident? This case is really an extension of that scenario over a longer time period. In general, parents should have rights to decide what care their child does or does not receive. We may not agree with their decision, but it usually does not warrant any legal intervention on our part. When the parents' decision is basically a death sentence for the child, we need to act.

Would your opinion change if the child did want the treatment and was begging to be saved, but the parents would not consent? It shouldn't. The child is by law unable to make this decision and unable to understand its consequences. That does not mean a child has no rights. It is part of our duty as physicians to make sure those rights, including a right to life, are protected.

In general, yes, I believe they should have the right to refuse. I do believe that in a life threatening situation, you should be allowed to administer standard medical care without any consent, so you would need an actual refusal to have to stop. I vehemently disagree that as physicians, a respect for human life equals trampling on people's religious beliefs and opinions about life, death, and disease. I can tell you this, I am not personally much of the opinion that any of these things have to do with my eternal soul, but if I believed that a physician were jeapordizing my child's eternal salvation with some medical intervention, you better believe that there would be hell to pay. This general idea that floats around that people's religious beliefs are all fine and dandy until they actually interfere with what we think people should do in any way is garbage.

As far as the question of the child begging to be saved, teenagers are repeatedly treated to a degree of autonomy in decision making all throughout the legal system. One needs to look no farther than an average everyday custody battle in a divorce. They can even access certain types of medical care without parental consent. Teens can access treatments with real side effects, including abortion and venereal disease treatment without their parents even being informed (let alone consulted) in many states. Teenagers are complicated, because understanding of consequences and degree of maturity can vary markedly from person to person. Parents may lose their rights regarding their children when the decisions that they make are not intended to be in the best interest of the child. If a parent were to sell a child for sex for secondary gain as an example, it is clear that this is a parent not attempting to act in the best interest of the child. Child abuse may be another, though even the way that we've decided to define that in such a sweeping manner sometimes bothers me. In a legal sense, one might argue that parents who were in diametric opposition to their child's point of view on his potentially life ending struggle, there is precedent that a minor may sometimes be given some autonomy in these decisions.

 

[docB]

As far as the question of the child begging to be saved, teenagers are repeatedly treated to a degree of autonomy in decision making all throughout the legal system. One needs to look no farther than an average everyday custody battle in a divorce.

Or the fact that teens are frequently charged as adults for criminal acts.

 

[LiveUninhibited]

In this case, given the '90% cure' opinion, it seems fairly straightforward. But at what % are the parents no longer endangering the child's life by foregoing treatment? At what point do the dangers of the treatment itself endanger the child more?

The boy and parents would have to understand what the odds are in order to reject the treatment and exercise their right to informed consent in any meaningful way. For more dire and certain consequences we would reasonably require higher levels of decision competence on the patient's part. Clearly neither the parents nor "child" (he's 13?! is he ******ed?) have a realistic idea of what's going on. I'd be more inclined (though I'd refer to a psychiatrist) to let him refuse the treatment if he could honestly say he would rather die than undergo chemotherapy, rather than his false notion that he is not sick. I'm also not really into parents rights, especially when they're this stupid.

Or the fact that teens are frequently charged as adults for criminal acts.

Teens are expected to exhibit adult competency and yet are not given adult priviledges. They can be taxed but can't even vote. They can be put away for life but can't enter into contracts or give consent to sexual activities. I suppose it must all be for their own good. The sooner we dismantle parental rights, the better, but I do fear that instead of transferring autonomy to those young people who are competent the state will merely replace parental tyranny with governmental tyranny.

 

[facetguy]

Looks like the boy and his mom are on the run:
http://www.msnbc.msn.com/id/30824587/

 

[LiveUninhibited]

Looks like the boy and his mom are on the run:
http://www.msnbc.msn.com/id/30824587/

hm... I guess I'm not for hunting them down to force him to live, either. Gotta love the "contempt of court" charge, as if courts don't deserve contempt. Unfortunately the only option for them is to move to a non-extraditing country.

 

[oldbearprofessor]

I can tell you this, I am not personally much of the opinion that any of these things have to do with my eternal soul, but if I believed that a physician were jeapordizing my child's eternal salvation with some medical intervention, you better believe that there would be hell to pay. This general idea that floats around that people's religious beliefs are all fine and dandy until they actually interfere with what we think people should do in any way is garbage.

If I, as a neonatologist, obtained a court order to transfuse your premature infant whose hematocrit was < 15 and who was in heart failure due to that and a large PDA/VSD, etc, what would you do to me if you did not wish that for religious reasons? I'm not asking your opinion on whether I should obtain the order, I will ask the court for it (custody) and, as I believe in the rule of law, I will follow the decision of the judge . I'm curious what you would do or think should be done to me (or the judge?/society?) and how you would do it?

 

[Rendar5]

If I, as a neonatologist, obtained a court order to transfuse your premature infant whose hematocrit was < 15 and who was in heart failure due to that and a large PDA/VSD, etc, what would you do to me if you did not wish that for religious reasons? I'm not asking your opinion on whether I should obtain the order, I will ask the court for it (custody) and, as I believe in the rule of law, I will follow the decision of the judge . I'm curious what you would do or think should be done to me (or the judge?/society?) and how you would do it?

Y'know, for some reason, I'm ok with the judge and society rejecting your request and letting the premie die, but I'm not ok with the mom and her kid refusing chemo in favor of alternative medicine. I guess the closes reason I could give is that I fully understand that not providing care and just giving alternative treatment would leave the infant in a high-mortality situation.

I think the reason why I'm in favor of the judge in this case isn't that we're forcing something on them they don't want. It's that they don't want to understand that their current actions place the child's life in jeopardy. If it was as simple as: "yes judge, we know he's sick and without treatment he will probably die and with treatment he will probably live, and we would only like to use alternative treatment in the hopes that it will help him; we do understand that there's no real evidence for this, but we believe it may work and is the best course of action in line with our religious beliefs."

Y'know I think that's all I want to be able to let them abstain from chemo. I just want them to understand the gravity of their decisions and the potential impct it will have. If you know that medically speaking you are making the wrong decision, but you are making the best decision for yourself personally, I'm fine letting something horrible happen to your child. And if you're an adult, do as you will: it's your life and if you don't want to understand your decision (as long as you're a&ox3 and aren't gonna harm someone else), be that way.

 

[edmadison]

Ultimately, this issue, like many in medical ethics, is a line drawing problem. The extremes, are easy cases. Most would say it is OK to force treatment for easily correctable acute illnesses in young children (e.g. ABX for pneumonia in an infant). On the other end, few would say it's OK to force a 17 year-old to endure a third course of chemo which has a minimal chance of inducing remission and would make his last few months miserable. The question is where is the line?

The courts look to the pros and cons of treatment, as well as the child's wishes and the maturity of the child in reaching that decision. This particular case seems pretty easy from the judge's standpoint (In my opinion). Ultimately, it comes down to where you want to draw the line. Will the child's wishes be absolute? At any age? What if the child's wishes conflict with the parents? Are the parents "rights" absolute?

Ed

 

[Miami_med]

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