Navigating parental disagreement: ethical analysis and a proposed approach

Shared decision-making in pediatrics can be problematic when disagreements arise. The impermissible-permissible-obligatory (I-P-O) framework helps define the limits of parental authority when clinicians disagree with parents. There is little guidance in the literature, however, on making critical clinical decisions when parents disagree with each other. We use a clinical case involving parental disagreement over resuscitation at borderline gestational age to provide context for an analysis of several potential approaches based on established ethical principles of pediatric decision-making. We identify four potential options for delivery room care: (1) Defer to the pregnant parent; (2) withhold resuscitation unless both parents agree to it; (3) attempt resuscitation if either parent requests it; (4) decide about resuscitation using a framework of advisability. The merits and flaws of each approach are discussed. We propose an expansion of the I-P-O framework that uses consideration of clinical details, an assessment of the patient's best interest, and parental values to determine clinical advisability to guide decision-making in the setting of parental discordance.