Options, Ethics, and Moral Imperatives

Vaccinations. Circumcisions. Birthing interventions. These are among the parenting topics that stir up strong feelings and can lead to the exchange of strong words. The recent heated debate over a circumcision post I wrote is one example of this, but there are countless others in fora and on blogs all over the web. In any case, all of this has gotten me thinking about differences in parenting styles. When do philosophical differences become true cases of “right” versus “wrong”?

To illustrate, while discipline styles fall along a continuum, involved parents can generally be classified as authoritarian (strict disciplinarians who don’t display much affection), authoritative (moderate disciplinarians with a warm parenting style), or permissive (non-disciplinarians who display significant affection). Several studies have demonstrated that authoritative parents raise the most well-adjusted, competent children (see, for instance, Lamborn et al, Steinberg et al, Dombusch et al). Furthermore, a recently published study on the topic suggests that authoritarian parenting is associated with future delinquent behavior (Trinkner et al). Still, though the evidence is mounting that children of authoritative parents do best in school and are least likely to engage in risky behaviors of various sorts later in life, parenting style is considered a matter of philosophy, and is left up to the parent (provided the child is not being neglected or abused). Abuse and neglect aside, the overarching social philosophy regarding discipline is that the parent(s) know the child best, and will act in the best interest of the child.

Let’s take another example. As I’ve pointed out here and here, there is neither scientific evidence to support routine infant circumcision, nor is there scientific evidence proving it is harmful in any way. As such, while it’s possible to debate circumcision on moral/ethical grounds (and to feel very strongly about it), the overarching social philosophy is that it’s up to the parent(s) to make the decision regarding circumcision. While there are some who feel very strongly about circumcision (including both those who think circumcision is a violation of the infant’s rights AND those who think that to forgo circumcision is an affront to god), the procedure is not legislated in the United States. Neither is it either supported or opposed by large medical organizations in this country (at this time, at least; there are stirrings that the American Academy of Pediatrics might support circumcision to some extent in the coming years).

Moving on. Vaccination gets a bit trickier, as both camps that feel strongly about the vaccination issue think that there is actual, physical harm being visited upon the child being (or not being) vaccinated. Anti-vaccination advocates think that vaccinating parents are exposing their children to unsafe substances, while proponents of vaccination worry about the children of the anti-vaxers AND about their own children (because the higher the percent of vaccinated individuals in a population, the better EVERYONE, including the vaccinated individuals, is protected). Vaccinations are legislated to some extent; the U.S. Centers for Disease Control and Prevention keeps a database of which vaccinations are required for entry into public school by state. The legislation of vaccinations helps improve compliance among those parents who don’t feel strongly either way about immunizing children, but parents who are fervently anti-vaccination can get an exemption on any one of a number of grounds (philosophical, religious, etc). Nevertheless, some pediatricians feel strongly enough about the dangers associated with children remaining unvaccinated that they won’t accept unvaccinated children into their practice (both to avoid exposing patients to unvaccinated children and to try to motivate parents to vaccinate). Other pediatricians feel that this exclusion of unvaccinated children is unethical. Given that the scientific evidence unequivocally supports childhood vaccination (more articles on this topic archived here), is it ethical to allow a parent who claims that vaccinations are harmful to make a potentially dangerous decision for their child? Is being wrong about the science the same thing as being wrong about the parenting?

Here’s yet another example. There was an ethical discussion written up in the medical journal Pediatrics last year about a case in which parents refused antibiotics and hospitalization for a septic (that is to say, bacterially-infected) newborn (Simpson et al). The mother had been trying for a home birth with a midwife, but had developed a fever and was brought to the hospital. The parents refused fetal monitoring and wanted to continue with their natural birth plan, despite concerns on the part of the medical team that both the mother and newborn had a bacterial infection. The mother eventually accepted IV antibiotics. She refused any treatment for her newborn, however, and asked to be discharged same-day. She and her husband wanted to leave against medical advice because they felt the newborn “didn’t look sick.” The medical team ended up contacting CPS, and the parents agreed to an antibiotic treatment for the newborn. Medical protocol would have been for the newborn to remain in the hospital for 48 hours of monitoring. Instead, however, the parents found another doctor who had privileges at the hospital and who agreed to discharge the baby early. The purpose of the article was to discuss what had been done and what should have been done. The authors of the article, all medical practitioners, agreed that the parents were doing what they (the parents) thought (in the absence of any medical knowledge) was in the best interest of the baby. This was not a case of purposeful abuse or neglect. However, the parents refused to allow the majority opinion of medical experts to guide their decision-making, and instead found a rogue practitioner willing to do what they wanted. Everyone agreed that, given the parents clearly loved the child, it was a shame to have had to bring CPS into the equation Still, the authors further agreed that when it comes to medical decisions, there’s a line between a parent exercising a parental right…and a parent simply being wrong.

With regard to some parenting issues, there’s no clear right or wrong answer. For instance, a few real sticklers on either side of the fence might butt heads over whether a 22-month-old should be allowed to watch TV, but there’s no rational argument that can be made for legislating this issue either way. There are other parenting issues that are clear-cut cases of moral imperative. For instance, it is wrong to keep a child in a kennel. No discussion, no ifs, ands, or buts. It’s wrong. And it’s illegal. Unfortunately, though, the waters are pretty muddy with regard to many other parenting decisions. Sure, the science supports breastfeeding, but what if mama hates it? What if she has to return to work and can’t pump? What if…whatever? Even when science comes down (either weakly or strongly) on one side of an argument, there’s often room for different philosophies. But then again, sometimes there isn’t.

Isaac Asimov, ca 1965

I guess the real question is how do we know what delineates a difference of philosophy and what’s simply a case of right and wrong? Should a set of parents be allowed to feed their newborn nothing but raw vegetable juice — because, say, they’re vegans who further happen to believe that soy is unhealthy due to…whatever — given that this diet would result in massive malnutrition (and eventually death)? Is it the right of a parent who wants a “natural birth experience” to leave the hospital against medical advice with a neonate that the medical staff feel needs antibiotics? If the parents leave and the infant lives, does that make them any less negligent than if they had left and the infant had died? Where’s the line between persevering in a philosophy…and perseverating? When does adherence become obstinance? The availability of free information (much of it erroneous) on the Internet has made many of us feel like armchair Experts In Everything. We tend to turn to the Internet rather than true experts, or we choose to trust only those experts who agree with our preformed, Interwebs-derived conclusions. Further, somehow it has become acceptable — in some circles, even admirable — to defy the medical and scientific establishments, and to refuse to acknowledge the validity of well-performed, oft-repeated, well-accepted research. How did this happen? In the words of Isaac Asimov, who said it so gracefully, “Anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that ‘my ignorance is just as good as your knowledge.’”

 

What do you think a parent should — or should not — be able to choose for their child?

 

References:

Dombusch et al. The relation of parenting style to adolescent school performance. Child Dev. 1987 Oct;58(5):1244-57.

Lamborn et al. Patterns of competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1991 Oct;62(5):1049-65.

Simpson et al. When parents refuse a septic workup for a newborn. Pediatrics. 2011 Nov;128(5):966-9. Epub 2011 Oct 24.

Steinberg et al. Over‐time changes in adjustment and competence among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1994 Jun;65(3):754-70.

Trinkner et al. Don’t trust anyone over 30: parental legitimacy as a mediator between parenting style and changes in delinquent behavior over time. J Adolesc. 2012 Feb;35(1):119-32. Epub 2011 Jun 12.