Caring for Children: Consent and Decision-making

Jonathan Choo Tze Liang

In recent years, cases of disputes arising between parents and medical professionals on the appropriateness of the care of children have come to the attention of the media and courts.1,2 When a child is critically ill, the decision on whether to continue life–sustaining treatment is often particularly emotive.3 Even in the primary care setting, there may be tensions that disrupt the attending medical professionals' relationship with the family or which result in quarrels within the family.4 The crux of the matter is to provide holistic care that is evidence–based and morally sound to the family and the child.

Concerning children and adolescents

On 15 April 2023, the SMA Centre for Medical Ethics and Professionalism organised a symposium titled "Decision-Making in the Care of Children – Who Decides?". It was well attended by 49 family physicians and paediatricians. The first talk titled "Consent in Children and Adolescents – Who Decides?" outlined the ethical underpinnings of consent and decision-making in the paediatric context. There was a consideration of how the medical care of children is typically a "triadic relationship", compared to a "dyadic relationship" in the care of an adult patient.

The "best interests" test was then examined as the orthodox position within the therapeutic relationship in the care of the child. The "significant harm" test was also suggested as a reasonable supplementary test and a lower bar, below which harm to the child would be unacceptable. The zone between the higher bar of "best interests" and the lower bar of "significant harm" was explored as the "zone of parental discretion" within which parental wishes may be acceded to,5 particularly when shared therapeutic aims and goals have been agreed upon. The talk concluded with a discussion on the process of shared decision-making in the care of children.

Next was a combined lecture titled "Engaging Children and Adolescents in the Decision-Making Process", delivered by Clinical A/Prof Chan Mei Yoke, a paediatric haematologist/oncologist and palliative care physician, and Dr Kumudhini Rajasegaran, paediatrician and adolescent medicine physician. A/Prof Chan spoke on the rights of the child and the current landscape and processes for child protection in Singapore. Dr Rajasegaren then delivered an interesting lecture with advice on how medical professionals could better engage adolescents in their care.

The final segment of the symposium was a discussion of paediatric cases with ethical issues presented to primary care physicians in attendance. This discussion was led by Dr Lim Hui Ling from the International Medical Clinic. Both the attendees and faculty had a lively discussion around Gillick competence and COVID-19 vaccination as the symposium concluded.6


When parents and medical professionals disagree, it is often a matter of perspective on the value of treatment and quality of life. Within the therapeutic relationship, communication is key.7 It is in only a small number of cases that an agreement cannot be reached, and these are the cases that come to the attention of the courts.8

  1. Goold I. Evaluating 'Best Interests' as a Threshold for Judicial Intervention in Medical Decision-Making on Behalf of Children. In: Goold I, Herring J, Auckland C. Parental Rights, Best Interests and Significant Harms: Medical Decision-Making on Behalf of Children Post-Great OrmondStreet Hospital v Gard. Oxford: Hart Publishing, 2019:29-47.
  2. Alder Hey Children's NHS Foundation Trust v Evans & Ors. [2018] EWHC 308 (Fam).
  3. Great Ormond Street Hospital v Yates & Ors. [2017] EWHC972 (Fam).
  4. Lam L. Court rules in favour of father who wants his 16-year-old child vaccinated but whose ex-wife opposes. CNA [Internet]. 26 April2022. Available at:
  5. McDougall R, Gilliam L, Gold H. The Zone of Parental Discretion. In: McDougall R, Delany C, Gillam L. When Doctors and Patients Disagree: Ethics, Paediatrics and the Zone of Parental Discretion. Sydney: The Federation Press, 2016:14-24.
  6. Gillick v West Norfolk and Wisbech AHA [1986] AC 112 at 184.
  7. Wilkinson D, Savulescu J. Embracing Disagreement. In: Wilkinson D, Savulescu J, eds. Ethics, Conflict and Medical Treatment for Children: From Disagreement to Dissensus. London (UK): Elsevier, 2018:121-5.
  8. George R. The Legal Basis for the Court's Jurisdiction to Authorise Medical Treatment of Children. In: Goold I, Herring J, Auckland C. Parental Rights, Best Interests and Significant Harms. Oxford: Hart Publishing, 2019:67-79.

Jonathan Choo Tze Liang is head and senior consultant pediatric cardiologist at KK Women's and Children's Hospital. His subspecialty interest is in fetal cardiology. He is a member of the Hospital Ethics Committee and has completed a Master of Public Health (University of London) and a Master of Healthcare Law and Ethics (University of Manchester).


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