The Journal of Clinical Ethics: Tables of Contents 2019 The Journal of Clinical Ethics, Volume 30, Number 3, Fall 2019 At the Bedside Treating Children Maximally: Practical Applications Edmund G. Howe, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 171-82. Lainie Friedman Ross suggests that clinicians increase our efforts to meet children’s most basic needs in several ways. These include prioritizing, to a greater extent, children’s present and future feelings; placing greater decisional weight on other family members’ needs; spotting earlier threats from surrogate decision makers so that we can better prevent these threatened harms; and finding ways to intervene earlier so that we can allow parental surrogate decision makers to remain in this role. I offer some practical ways in which Ross’s ideas might be applied. Features Better than Best (Interest Standard) in Pediatric Decision Making Lainie Friedman Ross, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 183-95. Healthcare decision making for children has adopted the best interest of the child standard, a principle originally employed by judges to adjudicate child placement in the case of parental death, divorce, or incompetence. Philosophers and medical ethicists have argued whether the best interest principle is a guidance principle (informing parents on how they should make healthcare decisions for their child), an intervention principle (deciding the limits of parental autonomy in healthcare decision making), or both. Those who defend it as only a guidance principle often cite the harm principle as the appropriate intervention principle. In this article, I challenge current use of the best interest principle in pediatric decision making as a guidance principle and as an intervention principle. I propose a model that I call constrained parental autonomy, which focuses on promoting and protecting the child’s primary goods or basic needs. I show that constrained parental autonomy can serve as both a guidance principle and an intervention principle in making decisions. I conclude by examining a case study involving bone marrow donation by a young child to her sister. Offering the “Reasonable Interests Standard” in Response to Ross’s Analysis of the Best Interests Standard D. Micah Hester, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 196-200. Ross’s argument against the best interest standard (BIS) makes a clear case for the problems of the BIS, and she also notes challenges with such notions as the harm principle. In light of these critiques, Ross champions her longstanding pediatric moral norm for decision making, constrained parental autonomy (CPA). This article argues that while Ross’s critique of the traditional accounts of the BIS is correct, her solution still raises some concerns. As such, I offer the “reasonable interests standard” as a way of addressing what I see as weaknesses in both the BIS and CPA. Guidance and Intervention Principles in Pediatrics: The Need for Pluralism Mark Christopher Navin and Jason Adam Wasserman, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 201-6. Two core questions in pediatric ethics concern when and how physicians are ethically permitted to intervene in parental treatment decisions (intervention principles), and the goals or values that should direct physicians’ and parents’ decisions about the care of children (guidance principles). Lainie Friedman Ross argues in this issue of The Journal of Clinical Ethics that constrained parental autonomy (CPA) simultaneously answers both questions: physicians should intervene when parental treatment preferences fail to protect a child’s basic needs or primary goods, and both physicians and parents should be guided by a commitment to protect a child’s basic needs and primary goods. In contrast, we argue that no principle—neither Ross’s CPA, nor the best interest standard or the harm threshold—can serve as both an intervention principle and a guidance principle. First, there are as many correct intervention principles as there are different kinds of interventions, since different kinds of interventions can be justified under different conditions. Second, physicians and parents have different guidance principles, because the decisions physicians and parents make for a child should be informed by different values and balanced by different (potentially) conflicting commitments. Decision Making on Behalf of Children: Understanding the Role of the Harm Principle Douglas S. Diekema, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 207-12. Thirty years ago, Buchanan and Brock distinguished between guidance principles and interference principles in the setting of surrogate decision making on behalf of children and incompetent adult patients. They suggested that the best interest standard could serve as a guidance principle, but was insufficient as an interference principle. In this issue of The Journal of Clinical Ethics, Ross argues that the best interest standard can serve as neither a guidance or interference principle for decision making on behalf of children, but that her model of constrained parental autonomy can serve as both. I will argue that Buchanan and Brock were correct that a single model or standard cannot serve as both a guidance and interference principle in pediatrics and that the best interest standard is a sufficient guidance principle. The harm principle fulfills the conditions necessary for an interference principle, at least insofar as deciding when state intervention to interfere with parental decision making is justified. When Better Isn’t Good Enough: Commentary on Ross’s “Better than Best (Interest Standard) in Pediatric Decision Making” Erica K. Salter, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 213-7. In this commentary, the author discusses two strengths and two weaknesses of “Better than Best (Interest Standard) in Pediatric Decision-Making,” in which Lainie Friedman Ross critiques the best interest standard and proposes her own model of constrained parental autonomy (CPA) as a preferable replacement for both an intervention principle and a guidance principle in pediatric decision making. The CPA’s strengths are that it detaches from the language and concept of “best” and that it better respects the family as a distinct and intimate decision-making unit. The first weakness of the framework, as an intervention principle, is that because it imports a Rawlsian understanding of basic interests, it neglects certain populations of children (for example, children with intellectual disabilities). The second weakness is that, as a guidance principle, it is unclear what actual guidance the CPA is positioned to offer and how that guidance would be justified. To conclude, this commentary offers suggestions for what should be required of both an intervention principle and a guidance principle in pediatric decision making. Constrained Parental Autonomy and the Interests of Children in Non-Intimate Families Erin Paquette, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 218-22. Children’s age and developmental capacity leave them incapable of making medical decisions for themselves. Decisions for children are traditionally made under the best interest standard. Ross calls into question whether the best interest standard can function as both a guidance and intervention principle, able to be applied across the spectrum of pediatric decision making. Ross describes constrained parental autonomy as an alternative model, arguing that it affords parents the ability to make decisions within the context of their family while upholding a child’s current and future interests. Although the model provides a robust framework for intrafamilial decision making, I question whether it can be broadly applied to children living in non-intimate families. The Best Interest Standard Is the Best We Have: Why the Harm Principle and Constrained Parental Autonomy Cannot Replace the Best Interest Standard in Pediatric Ethics Johan C. Bester, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 223-31. While the best interest standard (BIS) enjoys wide endorsement as ethical and decision-making standard in pediatrics, it has been criticized as vague and indeterminate. Alternate decision-making standards have been proposed to replace or augment the BIS, notably the harm principle (HP) and constrained parental autonomy (CPA) model. In this edition of The Journal of Clinical Ethics, Lainie Friedman Ross argues that CPA is a better standard than the BIS or the HP as both guide and limiter in pediatrics. In response, I review the important work done by the BIS in pediatrics, and argue that neither the HP nor the CPA can take over these functions or replace the BIS. Among other things I argue: (1) The BIS provides more robust protections for the moral claims of children. (2) The CPA model and the HP do not resolve the indeterminacy and vagueness present in complex medical situations, and the BIS is better suited to deal with this vagueness and indeterminacy. (3) The BIS is a general principle of medical ethics with special application in pediatrics; it fits seamlessly into the system of medical ethics and fulfills many functions within pediatrics. The HP and the CPA model do not fit in so readily within medical ethics, and are not equipped to take over the functions of the BIS. In Further Defense of “Better than Best (Interest)” Lainie Friedman Ross, The Journal of Clinical Ethics 30, no. 3 (Fall 2019): 232-9. In their thoughtful critiques of my article “Better than