Maggie Taylor

Children are presumptively regarded as incompetent to make their own medical decisions, and the responsibility for making such decisions typically falls to parents. Parental authority is not unlimited, however, and ethical guidelines identifying appropriate bounds on this authority are needed. One proposal currently gaining support is the Harm Threshold (HT), which asserts that the state may only legitimately intervene in parental decision-making when serious and preventable harm to children is likely. This paper considers two questions: in virtue of what underlying principle or property does the HT gain its purported justification?; and does this underlying principle or property ground the HT as its proponents conceive of it? I identify two separate grounds represented in the literature: (i) J.S. Mill’s Harm Principle; and (ii) the liberty interests of parents. I find that the HT is not sufficiently grounded in either of these, revealing a substantial conceptual difficulty for its advocates.

This paper advances a novel conception of the child’s best interest in regard to pediatric surgeries that do not promote the preventive or therapeutic health needs of children, or elective pediatric surgeries (EPS). First, children’s capacity for decision-making is examined, and the best decision-making model for EPS is identified as the Best Interest Standard. What follows is a discussion of the interests of children in the context of EPS, the correlation of fundamental interests to rights, and guidelines for weighing children’s competing interests. Next, the rights and duties of parents as proxy decision makers are considered. Finally, a reinterpretation of the Best Interest Standard is proposed, identifying as paramount a child’s ability to make elective medical decisions for herself when she reaches maturity.

The Harm Threshold (HT) holds that the state may interfere in medical decisions parents make on their children’s behalf only when those decisions are likely to cause serious harm to the child. Such a high bar for intervention seems incompatible with both parental obligations and the state’s role in protecting children’s well-being. In this paper, I assess the theoretical underpinnings for the HT, focusing on John Stuart Mill’s Harm Principle as its most plausible conceptual foundation. I offer (i) a novel, text-based argument showing that Mill’s Harm Principle does not give justificatory force to the HT; and (ii) a positive account of some considerations which, beyond significant harm, would comprise an intervention principle normatively grounded in Mill’s ethical theory. I find that substantive recommendations derived from Mill’s socio-political texts are less _laissez-faire_ than they have been interpreted by HT proponents. Justification for state intervention owes not to the severity of a harm, but to whether that harm arises from the failure to satisfy one’s duty. Thus, a pediatric intervention principle derived from Mill ought not to be oriented around the _degree_ of harm caused by a parent’s healthcare decision, but rather, the _kind_ of harm—specifically, whether the harm arises from violation of parental obligation. These findings challenge the interpretation of Mill adopted by HT proponents, eliminating a critical source of justification for a protected domain of parental liberty and reorienting the debate to focus on parental duties.