Doctors’ “judgements” and parents’ “wishes”: ethical implications in conflict situations

This terminology is also reflected in ethics literature discussing conflicts between parents and doctors. Our brief search of prominent ethics journals for articles about conflict cases published in the past decade confirmed our observation that clinicians are more likely to be described as “judging”, “assessing” or “recommending”, whereas parents “wish”, “want” or “demand”. A typical example relates to the well-known case of Charlotte Wyatt, a child with multiple complex medical problems resulting from prematurity. Charlotte’s doctors believed that ventilation would be inappropriate in the event that Charlotte contracted an infection. Charlotte’s parents pursued the case in court. One commentator wrote that the court “endorsed the professionals’ judgment” and that the “judge concluded that ... it was not in [Charlotte’s] best interests to require that doctors accede to her parents’ wishes”.1 Another piece analysing two different oncology cases referred to the convergence of “personal, social and cultural factors” that led the parents to “reject ... other more rational advice” from hospital staff.2 The language of doctors’ reasoned judgements and parents’ less reflective wishes seems widespread in both hospital settings and ethics literature, although there is little research specifically investigating doctors’ perceptions of parents’ decision making.3,4

From an ethics perspective, this language of judgements and wishes matters for (at least) two reasons. First, it implicitly privileges doctors’ views over parents’ views in conflict situations. The word “judgement” implies expertise and a reasoning process; judgements command respect. “Wish”, on the other hand, seems to imply mere preference. If we are considering what ought to be done in a situation in which the views of parents conflict with those of doctors, labelling the former “wishes” and the latter “judgements” sets us up to come to a particular conclusion. By such labelling, we are biasing our thinking in favour of the doctor’s view, and potentially contributing to a hidden curriculum that works against the overt focus in medical training on shared decision making and respect for autonomy.5

Second, this language matters because it invites us to see the views of doctors and parents in conflict situations as radically different in structure, not just content. We suggest that, in many cases, both parents and doctors are making ethical judgements about the most appropriate treatment option for a sick child. An ethical judgement can be understood as constituted by expertise in a particular domain, combined with a reasoning process based on a set of ethical values. Doctors’ expertise is biomedical and their ethical standpoint is usually a role-based one. Doctors tend to make decisions guided by their professional ethics, their notion of what it means to be a good doctor. However, increasing empirical evidence indicates that parents’ medical decision making for their children is also informed by a role-based ethical standpoint. Many parents are guided by their notions of what it means to be a good parent.6 Like doctors, parents have expertise; theirs is expertise about their family life. Thus, some parents can be understood as making ethical judgements about their child’s medical treatment. Rather than being radically different in structure, the views of doctors and parents can both be seen as judgements based on specific expertise and a role-based ethical standpoint.

A greater awareness of the language that we use when discussing conflicts between parents and doctors encourages us to be sensitive to the assumptions and biases that we are inadvertently inviting into our thinking. We suggest that, often, parents’ views are also judgements and are therefore worthy of greater respect than is encouraged when they are labelled “wishes”.