Pediatric cancer and ethical decision-making: Who speaks for the child?

Pediatric cancer care can generate difficult medical, ethical, and legal conflicts when parents, clinicians, and pediatric patients disagree about treatment. This review examines disputes involving aggressive therapy, transition to palliative care, treatment refusal, and requests for interventions with limited expected benefit.

This narrative review applies the principles of autonomy, beneficence, non-maleficence, and justice to evaluate how children's developing decision-making abilities, parental authority, and physicians' professional duties shape these conflicts. The harm principle and mature minor doctrine are considered in relation to the limits of parental discretion and the conditions under which institutional or state intervention may be justified.

The ethical weight of a child's treatment preferences depends on decision-specific understanding, expected clinical benefit, and treatment burden. Parental refusal of potentially curative therapy raises concern about serious preventable harm, whereas parental requests for interventions with limited expected benefit require assessment of proportionality and professional obligations. Illustrative legal disputes show that ethical judgments and legal authority must be distinguished. Evidence that ethics consultation or mediation reduces litigation or decisional conflict remains limited.

The review supports a child-centered decision-making approach that considers clinical evidence, treatment burden, family values, developmental capacity, and the pediatric patient's expressed preferences.

Decision-making authority must be distinguished from the child's ethical participation. The weight given to the child's preferences reflects an understanding of treatment benefits and burdens, and the risk of serious harm; legal authority follows applicable law. Pediatric oncology nurses can document the child's views and communicate concerns to team.