What is wrong with Best Interest Standard, Zone of Parental Discretion and the Harm Principle in paediatric decisions

Dr Ben Gray1

1University of Otago Wellington, Newtown Wellington, New Zealand

The Best Interest Standard (BIS) has been promoted for making decisions for children who lack capacity. This is uncontroversial: it describes standard modern patient centred care. The Calgary Cambridge guide to the medical interview 1 provides 71 items in a consultation needed to build a respectful trusting relationship and to develop an agreed management plan. It is harder to develop trust and reach an agreed management plan with patients who are culturally and linguistically diverse.

The widely used frameworks for addressing disagreements between clinicians and parents over the treatment of their child (BIS, Zone of Parental Discretion, Harm Principle) rely on the presumption that where  there  is disagreement, that the doctor’s view of BIS over-rides the parents’ view.  This requires abandoning good medical practice by not respecting the parents’ position and advocating coercion. This will decrease trust, disrupt the relationship, and, on occasion completely destroy the relationship, with the family fleeing all care.

I will argue that in the care of complex conditions it is unlikely that the harm caused by undermining relationship and trust will be balanced by the likely outcome of intervention.

In arguing my case I will consider,

  • case study evidence of harm from coercion,
  • the impact of culture (of both the patient and the doctor) on the development of trust
  • the likelihood that the clinician’s view of BIS will be in part based on bias, their own cultural values and an over reliance on the determinacy of “Evidence”.
  • The difference in managing “Complex” problems compared to “Obvious” problems2

I will conclude by suggesting that where there are unresolvable differences between clinicians and parents, the standard of care should be the engaging of an appropriate mediator (Clinical Ethics Advisor?) to work with clinician and parents to find the best available agreed management plan.


I work half time as a General Practitioner caring for a culturally and linguistically diverse practice with significant numbers of refugees. I am a senior lecturer in General Practice and Primary Health Care and convene the course in Professional Development Ethics and Health Law for our undergraduate students yrs 4,5 and 6.My research interests are varied but all relate to the care of unders-served populations. My particular interest is in the intersection between cultural competence and bioethics and health law