Informed Consent in Decision-Making in Pediatric Practice

POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Informed Consent in Decision- Making in Pediatric Practice COMMITTEE ON BIOETHICS

Informed consent should be seen as an essential part of health care abstract practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child’s and adolescent’s opinion in medical decision-making in clinical practice and research.

INTRODUCTION

This document is copyrighted and is property of the American Since the publication of previous American Academy of Pediatrics (AAP) Academy of Pediatrics and its Board of Directors. All authors have statements on informed consent in 1976 1 and 1995, 2 obtaining informed fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process permission from parents or legal guardians before medical interventions approved by the Board of Directors. The American Academy of on pediatric patients has become standard within our medical and legal Pediatrics has neither solicited nor accepted any commercial culture. The 1995 statement also championed, as pediatrician William involvement in the development of the content of this publication. Bartholome stated, “the experience, perspective and power of children” Policy statements from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (American in the collaboration between pediatricians, their patients, and parents Academy of Pediatrics) and external reviewers. However, policy and remains an essential guide for modern ethical pediatric practice. 2 statements from the American Academy of Pediatrics may refl ect the views of the liaisons or the organizations or government agencies that As recommended in the 1995 publication, this revised statement affirms they represent. that patients should participate in decision-making commensurate The guidance in this statement does not indicate an exclusive course with their development; they should provide assent to care whenever of treatment or serve as a standard of medical care. Variations, taking reasonable. Pediatric decision-making continues to evolve in response into account individual circumstances, may be appropriate. to changes in information technology, scientific discoveries, and legal All policy statements from the American Academy of Pediatrics rulings. Continuing limits on the widespread use of pediatric assent/ automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. refusal makes this review and restatement of AAP policy important. 3 DOI: 10.1542/peds.2016-1484 This policy statement provides a brief review of informed consent, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). including the ethical and legal roots, frameworks for surrogate decision- Copyright © 2016 by the American Academy of Pediatrics making, and information on special issues in informed consent in pediatric care. Recommendations on informed consent or refusal, parental permission, and assent in clinical practice and research are summarized at the end of this statement. A more detailed review of To cite: AAP COMMITTEE ON BIOETHICS. Informed Consent pediatric consent and decision-making can be found in the accompanying in Decision-Making in Pediatric Practice. Pediatrics. 2016; 138(2):e20161484 technical report to this policy statement. 4

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 :e 20161484 FROM THE AMERICAN ACADEMY OF PEDIATRICS PURPOSE OF INFORMED CONSENT TABLE 1 Elements of Informed Consent for Medical Decision-Making • Provision of information about the following: The current concept of informed o nature of the illness or condition consent in medical practice has roots o proposed diagnostic steps and/or treatments and the probability of their success within both ethical theory and law. o the potential risks, benefi ts, and uncertainties of the proposed treatment and alternative treatments, including the option of no treatment other than comfort measures The support for informed consent • Assessment of patient and surrogate understanding and medical decision-making capacity, including in ethical theory is most commonly assurance of time for questions by patient and surrogate found in the concept of autonomy. • Ensure that there is voluntary agreement with the plan The legal concept of informed consent has its roots in case law addressing issues of battery and TABLE 2 Practical Aspects of Assent by Pediatric Patients for Medical Decision-Making medical malpractice. The law has • Help the patient achieve a developmentally appropriate awareness of the nature of his or her condition evolved to require a full disclosure • Tell the patient what he or she can expect with tests and treatments to the patient of the facts necessary • Make a clinical assessment of the patient’s understanding of the situation and the factors infl uencing to form the basis of a reasonable, how he or she is responding (including whether there is inappropriate pressure to accept testing or therapy) informed consent. Informed consent • Solicit an expression of the patient’s willingness to accept the proposed care incorporates 3 duties: disclosure of information to patients and their surrogates, assessment of patient language during discussions with that challenges obtaining assent and surrogate understanding of minors, and information must be at younger ages. Alternatively, a the information and their capacity provided in a manner that respects developmental approach to assent for medical decision-making, and the cognitive abilities of the child anticipates different levels of obtaining informed consent before or adolescent. Clinicians should understanding from children as they treatments and interventions. use these opportunities to elicit age. 6 At a minimum, assent should information regarding their pediatric include the elements listed in Table This background helps us understand patient’s value-based treatment 2. Note that one should not solicit the conceptual difficulties goals and to assess whether there is a child’s assent if the treatment or encountered in trying to apply the adequate capacity for understanding intervention is required to satisfy framework of informed consent in and decision-making. Only patients goals of care agreed on by the the pediatric setting, in which most who have appropriate decisional physician and parent or surrogate, patients either lack the ability to capacity and who meet legal but the patient should be told that act independently or have limited requirements can give their informed fact and should not be deceived. or no capacity for medical decision- consent to medical care. Parents or Providing disclosure of appropriate making. Nevertheless, the goals of the other surrogates technically provide diagnostic and treatment information informed consent process (protecting “informed permission” for diagnosis and allowing choices about aspects and promoting health-related and treatment, with the assent of the of care, when possible, should be a interests and incorporating the child whenever appropriate. 2 When consistent part of the care plan for patient and/or the family in health defined as agreement with proposed children. care decision-making) are the same interventions, assent from children in the pediatric and adult population even as young as 7 years can foster Completely voluntary choice in and are grounded by the same ethical the moral growth and development treatments may be illusory in principles of beneficence, justice, and of autonomy in young patients. 2, 5 –7 general, but is particularly so in respect for autonomy. This consideration is based on pediatric care. Clinicians should be an understanding that, starting aware that parental decision-making FRAMEWORK FOR INFORMED around 7 years of age, children enter can be influenced by the quality of CONSENT/PERMISSION/ASSENT the concrete operations stage of the clinician-patient relationship, Knowledge about a medical condition development, allowing for limited previous medical knowledge, is critical to making informed health logical thought processes and emotional distress, faith, and critical 12 care decisions. Informed consent the ability to develop a reasoned changes in a child’s health status. 8–11 regarding medical care must decision. Decision-making by children and consistently incorporate several key adolescents is usually influenced components (see Table 1). A stricter interpretation of assent by their parents’ point of view requires that the minor meet and may not be entirely voluntary Pediatricians should be adept at all of the elements of an adult or autonomous. Unless there is using developmentally appropriate informed consent, a requirement significant coercion perceived

Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Standards for Surrogate Decision-Making in Pediatrics Best-interest standard Surrogate should aim to maximize benefi ts and minimize harms to the patient, while using a holistic view of the patient’s interests Harm principle Identify a harm threshold below which parental decisions will not be tolerated Constrained parental autonomy Parents may balance the best interest of the patient with the family’s best interest if the patient’s basic needs are met Shared, family-centered decision-making Process that builds on collaborative mechanism between families and clinicians by clinicians, this situation is not parents’ responsibility to support interests of the child’s family in the unacceptable, because medical the interests of their child and process of medical decision-making. decision-making cannot, and should to preserve family relationships, The harm principle may be seen as not, occur in a vacuum, isolated from rather than being focused on a more realistic standard to apply in all other concerns. Medical decision- their rights to express their own pediatric surrogate medical decision- making is not a discrete event but autonomous choices. By moving the making. The intent of the harm evolves over time among the health conversation from parental rights principle is not to identify a single care team, family, and pediatric toward parental responsibility, course of action that is in the minor’s patient as new information becomes clinicians may help families minimize best interest or is the physician’s available. conflicts encountered in the course preferred approach, but to identify a of more serious and difficult medical harm threshold below which parental decision-making. FRAMEWORK FOR DECISION-MAKING decisions will not be tolerated and outside intervention is indicated to Although commonly used in adult Medical decision-making in protect the child. 15 practice, substituted judgment is an pediatrics is informed by the cultural, The model of constrained parental uncommon standard for decision- social, and religious diversity of autonomy 16 allows parents, as making in the pediatric setting. physicians, patients, and families. surrogate decision-makers, to An exception occurs when mature The AAP recommends that infants, balance the “best interest” of the adolescents, usually those with children, and adolescents, regardless minor patient with his or her chronic diseases, have expressed of parental religious beliefs, receive understanding of the family’s best wishes about goals of care before effective medical treatment when interests as long as the child’s basic deterioration of cognitive function. such treatment is likely to prevent needs, medical and otherwise, are These wishes may be respected by substantial harm, serious disability, met. A parent’s authority is not parents and physicians in a manner or death. 13 Clinicians must balance absolute but constrained by respect similar to surrogate decision-making the need to work collaboratively for the child. for adults. The opportunity to with all parents/families, respecting provide guidance about their future Shared, family-centered decision- their cultures, religions, and the medical care should be discussed making, although not a standard, importance of the families’ autonomy during their ongoing health care is an increasingly used process and intimacy with the need to protect in a manner consistent with their for pediatric medical decision- children from serious and imminent cognitive development and maturity. making and builds on collaborative harm. For some mature adolescents, communication between families and Parents generally are better it must be recognized that they may clinicians. 17 situated than others to understand either endorse or reject the tenets of the unique needs of their children their parent’s faith over time. and to make appropriate, caring THE CHILD/ADOLESCENT AS MEDICAL Several standards for pediatric DECISION-MAKER decisions regarding their children’s decision-making have emerged in the health care. This is not an absolute literature (see Table 3). Historically, Pediatric practice is unique in legal right, however, because the medical decision-making in minors that developmental maturation state also has a societal interest has centered on the best-interest of the child allows for increasing in protecting the child from harm standard, which directs the surrogate longitudinal inclusion of the child’s (the doctrine of parens patriae) and to maximize benefits and minimize opinion in the decision-making can challenge parental authority in harms to the minor. 14 A broader process. Encouraging pediatric situations in which a minor is put at approach for using the best-interest patients to actively explore options significant risk of serious harm or standard is to acknowledge the and to take on a greater role in neglect. Parental decision-making pediatric patient’s emotional, social, their health care may promote should primarily be understood as and medical concerns along with the empowerment and compliance with

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 3 a treatment plan. With this in mind, appendectomy for acute appendicitis. adolescents’ access to mental health informed consent/assent should be In general, adolescents should not and substance abuse prevention and recognized as an essential part of be allowed to refuse life-saving treatment services. These changes health care practice. treatment even when parents agree reflect a public health concern that with the child. 22 – 24 In medical adolescents will not access these Adolescent decision-making is scenarios with a poor prognosis services if parental consent is dependent on several factors, and burdensome or unproven required. However, state statutes including cognitive ability, maturity interventions, more consideration that permit adolescents to consent to of judgment, and moral authority, should be given by the physician these services do not always protect which may not all proceed to to advocating for the cognitively their confidentiality. Practitioners maturation along the same timeline. mature teenager who wants to refuse should become familiar with their Many minors reach the formal treatment and uphold an adolescent’s state statutes on these issues and operational stage of cognitive assent or refusal for further attempts consider promoting changes in development that allows abstract at curative treatments. 25 legislation to improve adolescent confidentiality protection where thinking and the ability to handle Although there is still no bright line 18,19 appropriate. 26 complex tasks by midadolescence. demarcating when a minor becomes Brain remodeling with enhanced “mature” enough to independently connectivity generally proceeds The mature-minor doctrine satisfy the decision-making criteria recognizes that there is a subset through the third decade of life, for informed consent or refusal, the with the prefrontal cortex, the site of adolescents who have adequate courts have weighed in on this issue maturity and intelligence to of executive functions and impulse with a variety of outcomes, which control, among the last to mature. understand and appreciate an are detailed in the accompanying intervention’s benefits, risks, In contrast, the risk-taking and technical report. 4 sensation-seeking areas (limbic and likelihood of success, and alternatives paralimbic regions) develop around When conflicts about goals of and can reason and choose puberty. This temporal imbalance treatment persist despite guidance voluntarily. Most states have mature- or “gap” between the 2 systems can by the physician and a collaborative minor statutes in which the minor’s lead to the risky behavior seen in approach with the patient and family, age, overall maturity, cognitive adolescence. 20 A detailed discussion the primary health care team should abilities, and social situation as of the neurologic maturation of enlist the involvement of consultants, well as the gravity of the medical the adolescent brain is beyond including ethics consultation, situation are considered in a judicial the scope of this policy statement, psychologists, psychiatrists, determination, finding that an and the reader is referred to the chaplains, and, when appropriate, otherwise legally incompetent minor accompanying technical report. 4 an integrated palliative care team. is sufficiently mature to make a Seeking legal intervention should be legally binding decision and provide his or her own consent for medical The implications for decision-making a last resort. care. by adolescents in stressful health care environments are that they may In distinction, emancipated minor EXCEPTIONS TO LIMITATIONS rely more on their mature limbic statutes do not address decision- system (socioemotional) rather ON ADOLESCENT MEDICAL DECISION-MAKING making ability, but rather, the legal than on the impulse-controlling, and social status of the minor. less-developed prefrontal cognitive There are 3 broad categories of Adolescents living separately from 21 system. when a minor can legally make their parents and self-supporting, decisions regarding his or her own Dissent by the pediatric patient married, or on active duty with health care: exceptions based on should carry considerable weight the armed forces are generally specific diagnostic/care categories, when the proposed intervention is considered legally emancipated the “mature minor” exception, and not essential and/or can be deferred and able to provide informed legal emancipation. The legal ability without substantial risk. consent or refusal for their own of adolescents to consent for health medical care. If the likely benefits of treatment in care needs related to sexual activity, conditions with a good prognosis including treatment of sexually In all states, adolescent parents, outweigh the burdens, parents transmitted infections, contraceptive similar to other parents, are should choose a treatment plan services, and prenatal care, is presumed to be the appropriate over the objections or dissent recognized in all states. There has decision-makers for their children of the minor, as in choosing an been a similar expansion regarding and may give informed consent for

Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS their child’s medical care. This right RECOMMENDATIONS state laws on adolescent reflects the adolescent’s status as a treatment refusals is critical in 1. Physicians should involve parent. There is clearly a concerning these situations. pediatric patients in their paradox encountered when health care decision-making 6. Physicians have both a adolescents are allowed to make by providing information on moral obligation and a legal complex medical decisions for their their illness and options for responsibility to question and, child but cannot legally direct their diagnosis and treatment in a if necessary, to contest both the own medical care. 27 developmentally appropriate surrogate’s and the patient’s manner and seeking assent medical decisions if they put to medical care whenever the patient at significant risk of EMERGENCY EXCEPTIONS TO appropriate. INFORMED CONSENT serious harm. Children may present with 2. Parents should generally be 7. Physicians must realize that emergency medical conditions recognized as the appropriate informed consent/permission/ without a parent or legal guardian ethical and legal surrogate assent/refusal constitutes a available to provide consent. 28 In medical decision-makers for process, not a discrete event, addition to common and statutory their children and adolescents. and requires the sharing of law generally supporting the This recognition affirms parents’ information in ongoing physician- provision of emergently needed intimate understanding of patient-family communication and care, the Emergency Medical their children’s interests and education. respects the importance of family Treatment and Active Labor Act 8. Physicians must have access to autonomy. mandates that a medical screening and understanding of their specific examination and delivery of 3. Surrogate decision-making by state statutes governing the care appropriate medical care for the parents or guardians for pediatric of sexually transmitted infections, pediatric patient with an urgent or patients should seek to maximize provision of contraceptive emergent condition should never benefits for the child by balancing and abortion services, mental be withheld or delayed because of health care needs with social health and substance abuse problems with obtaining consent in and emotional needs within the treatment, and the definition and these situations in which a parent or context of overall family goals, care of the emancipated minor guardian is not available. religious and cultural beliefs, and and adolescents who possess values. decision-making capacity (mature minors). These statutes may not INFORMED CONSENT/ASSENT/REFUSAL 4. Physicians should recognize that include protection of adolescent IN RESEARCH INVOLVING CHILDREN some pediatric patients, especially confidentiality. AND ADOLESCENTS older adolescents and those with 9. Physicians who are involved medical experience because of In distinction from clinical practice, in clinical research must chronic illness, may possess there are clear federal mandates understand both the special adequate capacity, cognitive in research to obtain assent from place of assent in the process ability, and judgment to engage the child research subject and of enrolling children in clinical effectively in the informed consent informed permission from a subject’s research trials and the specific or refusal process for proposed parent(s). A minor’s dissent from additional protections that goals of care. study participation is also respected. regulate the participation of Although assent is mandated, 5. The dilemma of an adolescent children and adolescents as guidelines for how to obtain assent treatment refusal is ethically and research subjects. for research and at what age are emotionally challenging. Instances not explicit. Similar to concerns in which treatment burdens LEAD AUTHORS raised regarding adolescent refusal may outweigh benefits and fail Aviva L. Katz, MD, FAAP of life-saving therapy in the clinical to achieve a curative end should Sally A. Webb, MD, FAAP arena, the institutional review mandate thoughtful guidance from board can provide a waiver from the physician, with continued COMMITTEE ON BIOETHICS, 2015–2016 requiring assent if the research has communication among the patient, Aviva L. Katz, MD, FAAP, Chairperson the potential for an important direct surrogates, and health care team Robert C. Macauley, MD, FAAP benefit that is only available in the to clarify values and treatment Mark R. Mercurio, MD, MA, FAAP context of research. 29 goals. Knowledge of individual Margaret R. Moon, MD, FAAP

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 5 Alexander L. Okun, MD, FAAP Douglas S. Diekema, MD, MPH – American Board LEGAL CONSULTANTS Douglas J. Opel, MD, MPH, FAAP of Pediatrics Nanette Elster, JD, MPH Mindy B. Statter, MD, FAAP Dawn Davies, MD, FRCPC, MA – Canadian Pediatric Jessica Wilen Berg, JD, MPH Society Sigal Klipstein, MD – American College of CONTRIBUTING FORMER COMMITTEE STAFF Obstetricians and Gynecologists MEMBERS Florence Rivera, MPH Mary E. Fallat, MD, FAAP, Past Chairperson Alison Baker, MS FORMER LIAISONS Sally A. Webb, MD Kathryn L. Weise, MD Kevin W. Coughlin, MD, FAAP – Canadian Pediatric Society ABBREVIATION Steven J. Ralston, MD – American College of AAP: American Academy of LIAISONS Obstetricians and Gynecologists Pediatrics Mary Lynn Dell, MD, DMin – American Academy of Monique A. Spillman, MD, PhD – American College Child and Adolescent Psychiatry of Obstetricians and Gynecologists

FINANCIAL DISCLOSURE: The authors have indicated they do not have a fi nancial relationship relevant to this article to disclose. FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

REFERENCES 1. American Academy of 9. Ruhe KM, Wangmo T, Badarau DO, 16. Ross L. Children, Families, and Health Pediatrics. Consent. Pediatrics. Elger BS, Niggli F. Decision-making Care Decision-Making. New York, NY: 1976;57(3):414–416 capacity of children and adolescents— Oxford University Press; 1998 2. American Academy of Pediatrics, suggestions for advancing the 17. Committee on Hospital Care, American Committee on Bioethics. Informed concept’s implementation in Academy of Pediatrics. Family-centered consent, parental permission, and pediatric healthcare. Eur J Pediatr. care and the pediatrician’s role. assent in pediatric practice. Pediatrics. 2015;174(6):775–782 Pediatrics. 2003;112(3 pt 1):691–697 1995;95(2):314–317 10. Moore L, Kirk S. A literature 18. Weithorn LA, Campbell SB. The 3. Lee KJ, Havens PL, Sato TT, Hoffman review of children’s and young competency of children and adolescents GM, Leuthner SR. Assent for treatment: people’s participation in decisions to make informed treatment decisions. clinician knowledge, attitudes, and relating to health care. J Clin Nurs. Child Dev. 1982;53(6):1589–1598 2010;19(15–16):2215–2225 practice. Pediatrics. 2006;118(2): 19. McCabe MA. Involving children and 723–730 11. Miller VA, Drotar D, Kodish E. Children’s adolescents in medical decision 4. American Academy of Pediatrics, competence for assent and consent: making: developmental and clinical Committee on Bioethics. a review of empirical fi ndings. Ethics considerations. J Pediatr Psychol. Informed consent in decision Behav. 2004;14(3):255–295 1996;21(4):505–516 making in pediatrics. Pediatrics. 12. Lipstein EA, Brinkman WB, Britto 20. Steinberg L. A dual systems model of 2016;138(2):e20161485 MT. What is known about parents’ adolescent risk-taking. Dev Psychobiol. 5. Denham EJ, Nelson RM. Self- treatment decisions? A narrative 2010;52(3):216–224 review of pediatric decision making. determination is not an appropriate 21. Johnson SB, Blum RW, Giedd JN. Med Decis Making. 2012;32(2): model for understanding parental Adolescent maturity and the brain: 246–258 permission and child assent. Anesth the promise and pitfalls of Analg. 2002;94(5):1049–1051 13. American Academy of Pediatrics neuroscience research in adolescent 6. Miller VA, Nelson RM. A developmental Committee on Bioethics. Religious health policy. J Adolesc Health. approach to child assent for objections to medical care. Pediatrics. 2009;45(3):216–221 1997;99(2):279–281 nontherapeutic research. J Pediatr. 22. Diekema DS. Adolescent refusal of 2006;149(1 suppl):S25–S30 14. Kopelman LM. The best-interests lifesaving treatment: are we asking the 7. Unguru Y, Coppes MJ, Kamani N. standard as threshold, ideal, and right questions? Adolesc Med State Art Rethinking pediatric assent: from standard of reasonableness. J Med Rev. 2011;22(2):213–228, viii requirement to ideal. Pediatr Clin Philos. 1997;22(3):271–289 23. De Lourdes Levy M, Larcher V, Kurz North Am. 2008;55(1):211–222, xii 15. Diekema DS. Parental refusals of R; Ethics Working Group of the 8. Pretzlaff RK. Should age be a deciding medical treatment: the harm principle Confederation of European Specialists factor in ethical decision-making? as threshold for state intervention. in Paediatrics. Statement of the Ethics Health Care Anal. 2005;13(2):119–128 Theor Med Bioeth. 2004;25(4):243–264 Working Group of the Confederation

Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS of European Specialists in Paediatrics Available at: www.pediatrics. org/ cgi/ Med State Art Rev. 2011;22(2): (CESP). Informed consent/ content/ full/ 124/ 6/ e1142 240–250, ix Eur J Pediatr assent in children. . 26. Guttmacher Institute. Preventing 28. Committee on Pediatric Emergency 2003;162(9):629–633 cervical cancer: new resources to Medicine; Committee on Bioethics. 24. Ross LF. Against the tide: arguments advance the domestic and global Consent for emergency medical against respecting a minor’s refusal of fi ght. Guttmacher Policy Review. services for children and adolescents. effi cacious life-saving treatment. Camb Winter 2012;15:1. Available at: www. Pediatrics. 2011;128(2):427–433 Q Healthc Ethics. 2009;18(3):302–315; guttmacher.org/ pubs/ gpr/ 15/ 1/ 29. Wendler D, Belsky L, Thompson KM, discussion: 315–322 gpr150108. html. Accessed October 28, Emanuel EJ. Quantifying the federal 2013 25. Pousset G, Bilsen J, De Wilde J, et minimal risk standard: implications al. Attitudes of adolescent cancer 27. Mercurio MR. Adolescent mothers for pediatric research without a survivors toward end-of-life decisions of critically ill newborns: addressing prospect of direct benefi t. JAMA. for minors. Pediatrics. 2009;124(6). the rights of parent and child. Adolesc 2005;294(7):826–832

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/138/2/e20161484 References This article cites 26 articles, 7 of which you can access for free at: http://pediatrics.aappublications.org/content/138/2/e20161484#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Committee on Bioethics http://www.aappublications.org/cgi/collection/committee_on_bioethi cs Ethics/Bioethics http://www.aappublications.org/cgi/collection/ethics:bioethics_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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