Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis

Although there has been significant attention in clinical ethics to when physicians should follow a parent's wishes, there has been much less discussion of the obligation to solicit viewpoints and decisions from all caregivers who have equal moral and legal standing in relation to a pediatric patient. How should healthcare professionals respond when one caregiver dominates decision making? We present a case that highlights how these problems played out in an ethical bargain. Ethical bargaining occurs when the parties involved choose not to pursue a morally preferable option for the sake of coming to a resolution. This case is not one of parental disagreement; rather, the medical team agreed to exclude the patient's mother from decision making if the patient's father promised to bring their son back to the hospital for necessary medical tests. We argue that there is an obligation to notice and acknowledge power asymmetries in the family unit, which, in this case, was manifested as the marginalization of the female decision maker by the male decision maker. In these scenarios, clinicians should be careful to avoid treating parents as one homogenous unit, and they should take action to enable caregivers' autonomy and voice. While there are moral and practical limits to how and when physicians should intervene in family dynamics, we discuss the steps that the medical team should have taken in this case to avoid undermining the parental authority of the mother. We conclude by offering recommendations to address and enable caregivers' autonomy at an institutional level, and we discuss the importance of tracking and responding to damaging family dynamics to prevent ethically impermissible bargaining.