Informed Consent, Parental Permission, and Assent in Pediatric Practice
Committee on Bioethics
Since the 1976 publication of an AAP policy statement on the legal concept of informed consent in pediatric practice, the concept has evolved and become more formal.1 A better understanding now exists as to how physicians should collaborate with patients and parents in making these decisions. Patients should participate in decision-making commensurate with their development; they should provide assent to care whenever reasonable. Parents and physicians should not exclude children and adolescents from decision-making without persuasive reasons. Indeed, some patients have specific legal entitlements to either consent or to refuse medical intervention. Although physicians should seek parental permission in most situations, they must focus on the goal of providing appropriate care and be prepared to seek legal intervention when parental refusal places the patient at clear and substantial risk.2 In cases of serious conflict, physicians and families should seek consultative assistance and only in rare circumstances look to judicial determinations.
We now realize that the doctrine of "informed consent" has only limited direct application in pediatrics. Only patients who have appropriate decisional capacity and legal empowerment can give their informed consent to medical care. In all other situations, parents or other surrogates provide informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate.
In this statement, the AAP provides an updated analysis of 1) the concept of informed consent; 2) the ethics of informed consent and the concept of the right to refuse treatment; 3) the concept of "proxy consent"; 4) the concepts of parental permission and child assent; and 5) informed consent of adolescents.