1. Harrison et al. Bioethics for Children: Involving Children in Medical Decisions

2. Samantha’s case 11 years old with osteosarcoma in left arm Arm amputated & chemotherapy given Cancer free for 18 months before returning metastasizing in her lungs. 20% chance of “successful recovery” Samantha distrusts the health care workers and is angry at them and her parents. Samantha refuses further treatment

3. Ethics and including children Moving away from traditional model where physicians and parents made all medical decisions of behalf of children to one where children are increased involved somehow in the decision. Best to use a “family centred approach,” which considers consequences to all family members. Difficult here because disagreement in the family – the parents want to continue treatment.

4. Ethics and including children Triadic relationship that involves physicians, parents and child. The child’s input will depend on their level of cognitive and emotional development. The child must be worked with, by a variety of health care workers, to ensure s/he is made as capable as possible in dealing with the situation.

5. Law, children and proxy consent A patient's right to refuse even life saving treatment is recognized in Canadian law. “mature minor” recognizes that some children are competent to make medical decisions. When child not competent, the parents typically are the proxies but they must make decisions in the child’s best interets. They can’t be as idiosyncratic in their decisions – e.g., JH’s and blood transfusions. Restraints

6. Policy, etc. In CAN, no policy on the role of children. In US, policy is as above. Proxy but in best interests of child. Developmental psychology: infants & young children vs. primary school children vs. adolescents. Considerations: potential benefits to child; potential harmful consequences (including psychological etc); moral, spiritual and cultural values of the child’s family.

7. Case Samantha included in decisions, which involves a large team. Decide upon palliative care.