Problems arise when applying the current procedural conceptualization of decision-making capacity to paediatric healthcare: Its emphasis on content-neutrality and rational cognition as well as its implicit assumption that capacity is an ability that resides within a person jeopardizes children’s position in decision-making. The purpose of the paper is to challenge this dominant account of capacity and provide an alternative for how capacity should be understood in paediatric care. First, the influence of developmental psychologist Jean Piaget upon the notion of capacity is discussed, followed by an examination of Vygostky’s contextualist view on children’s development, which emphasizes social interactions and learning for decision-making capacity. In drawing parallels between autonomy and capacity, substantive approaches to relational autonomy are presented that underline the importance of the content of a decision. The authors then provide a relational reconceptualization of capacity that leads the focus away from the individual to include important social others such as parents and physicians. Within this new approach, the outcome of adults’ decision-making processes is accepted as a guiding factor for a good decision for the child. If the child makes a choice that is not approved by adults, the new conceptualization emphasizes mutual exchange and engagement by both parties.
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In the United Kingdom, the concept of capacity carries legal connotations and competence clinical ones (Bielby 2013).
This contextualized and social decision-making process is not unique to childhood but is also beneficial in adult care. We thank the anonymous reviewer for highlighting this important aspect.
Alderson, P. 1992. In the genes or in the stars? Children’s competence to consent. Journal of Medical Ethics 18(3): 119–124.
———. 2003. Die autonomie des kindes: Über die selbstbestimmungsfähigkeit von kindern in der medizin [Children’s autonomy: On children’s capacity to make decisions in healthcare]. In Das kind als patient—Ethische konflikte zwischen kindeswohl und kindeswille [Children as patients: Ethical conflicts between the child’s welfare and the child’s wishes], ed. C. Wiesemann, A. Dörries, G. Wolfslast, and A. Simon, 28–47. Frankfurt/Main: Campus Verlag.
———. 2007. Competent children? Minors’ consent to health care treatment and research. Social Science and Medicine 65(11): 2272–2283.
Alderson, P., and J. Montgomery. 1996. Health care choices: Making decisions with children, Vol. 2. Institute for Public Policy Research.
Alderson, P., K. Sutcliffe, and K. Curtis. 2006. Children’s competence to consent to medical treatment. Hastings Center Report 36(6): 25–34.
Appelbaum, P.S. 2007. Assessment of patients’ competence to consent to treatment. New England Journal of Medicine 357(18): 1834–1840.
Banner, N.F. 2013. Can procedural and substantive elements of decision-making be reconciled in assessments of mental capacity? International Journal of Law in Context 9(01): 71–86.
Beauchamp, T.L., and J.F. Childress. 2001. Principles of biomedical ethics. New York, NY: Oxford University Press.
Bielby, N.F. 2013. Can procedural and substantive elements of decision-making be reconciled in assessments of mental capacity? International Journal of Law in Context 9(1): 71–86.
Buchanan, A.E., and D.W. Brock. 1989. Deciding for others: The ethics of surrogate decision making. Cambridge: Cambridge University Press.
Brainerd, C.J. 1978. The stage question in cognitive-developmental theory. Behavioral and Brain Sciences 1(02): 173–182.
Bronfenbrenner, U. 1979. The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
Chaiklin, S. 2003. The zone of proximal development in Vygotsky’s analysis of learning and instruction. In Vygotsky’s educational theory in cultural context, ed. A. Kozulin, B. Gindis, V.S. Ageyev, and S.M. Miller. Cambridge: Cambridge University Press.
Charland, L. 2011. Decision-making capacity. In Stanford Encyclopedia of Philosophy. http://seop.illc.uva.nl/entries/decision-capacity/. Accessed June 13, 2015.
———. 1998. Appreciation and emotion: Theoretical reflections on the MacArthur treatment competence study. Kennedy Institute of Ethics Journal 8(4): 359–376.
Christman, J. 2003. Autonomy in moral and political philosophy. http://plato.stanford.edu/entries/autonomy-moral/. Accessed June 12, 2014.
———. 2004. Relational autonomy, liberal individualism, and the social constitution of selves. Philosophical Studies 117(1): 143–164.
Cornock, M. 2010. Hannah Jones, consent and the child in action: A legal commentary. Paediatric Nursing 22(2): 14–20.
Dittmann, V. 2008. Urteilsfähigkeit als Voraussetzung für Aufklärung und Einwilligung. Therapeutische Umschau 65(7): 367–370.
Etchells, E., G. Sharpe, C. Elliott, and P.A. Singer. 1996. Bioethics for clinicians: 3. Capacity. Canadian Medical Association Journal 155(6): 657–661.
Freeman, M. 2005. Rethinking Gillick. International Journal of Children’s Rights 13: 201–217.
Gabe, J., G. Olumide, and M. Bury. 2004. “It takes three to tango”: A framework for understanding patient partnership in paediatric clinics. Social Science & Medicine 59(5): 1071–1079.
Ganzini, L., L. Volicer, W.A. Nelson, E. Fox, and A.R. Derse. 2004. Ten myths about decision-making capacity. Journal of the American Medical Directors Association 5(4): 263–267.
Gilligan, C. 1982. In a different voice: Harvard University Press.
Graham, A., and R. Fitzgerald. 2010. Children’s participation in research. Some possibilities and constraints in the current Australian research environment. Journal of Sociology 46(2): 133–147.
Grisso, T., and L. Vierling. 1978. Minors’ consent to treatment: A developmental perspective. Professional Psychology 9(3): 412–427.
Held, V. 1993. Feminist morality: Transforming culture, society, and politics: University of Chicago Press.
———. 2007. Feminism and moral theory. Bioethics: An introduction to the history, methods, and practice: 158.
Hickey, K. 2007. Minors’ rights in medical decision making. JONAS Healthcare Law, Ethics, and Regulation 9(3): 100–104.
Hinds, P.S., D. Drew, L.L. Oakes, et al. 2005. End-of-life care preferences of pediatric patients with cancer. Journal of Clinical Oncology 23(36): 9146–9154.
Holaday, B., L. Lamontagne, and J. Marciel. 1994. Vygotsky’s zone of proximal development: Implications for nurse assistance of children's learning. Issues in Comprehensive Pediatric Nursing 17(1): 15–27.
Inhelder, B., H. Sinclair, and M. Bovet. 1974. Learning and the development of cognition. Translated by S. Wedgwood. Cambridge, MA, US: Harvard University Press.
Larcher, V., and A. Hutchinson. 2010. How should paediatricians assess Gillick competence? Archives of Disease in Childhood 95(4): 307–311.
Lo, B. 1990. Assessing decision‐making capacity. Journal of Law, Medicine and Health Care 18(3): 193–201.
Mackenzie, C. 2008. Relational autonomy, normative authority and perfectionism. Journal of Social Philosophy 39(4): 512–533.
Mackenzie, C., and W. Rogers. 2013. Autonomy, vulnerability and capacity: A philosophical appraisal of the Mental Capacity Act. International Journal of Law in Context 9(01): 37–52.
Mackenzie, C., and N. Stoljar. 2000. Relational autonomy: Feminist perspectives on automony, agency, and the social self. New York: Oxford University Press.
Marti, E. 1996. Mechanisms of internalisation and externalization of knowledge in Piaget’s and Vygotsky’s theories. In Piaget - Vygostky, The social genesis of thought, ed. A. Tryphon and J. Vonèche. East Sussex: Psychology Press.
Melton, G.B. 1983. Children’s competence to consent. In Children’s competence to consent, ed. G.B. Melton, G.P. Koocher, and M.J. Saks, 1–18. United States: Springer.
Mercurio, M.R. 2007. An adolescent’s refusal of medical treatment: Implications of the Abraham Cheerix case. Pediatrics 120(6): 1357–1358.
Miller, P.H. 1993. Theorien der entwicklungspsychologie [Theories in Developmental Psychology]. Heidelberg: Spektrum Akademischer Verlag.
Miller, R. 2011. Vygotsky in perspective. New York: Cambridge University Press.
Morrison, K.L., J.K. Morrison, and S. Holdridge-Crane. 1979. The child’s right to give informed consent to psychiatric treatment. Journal of Clinical Child & Adolescent Psychology 8(1): 43–47.
Murray, F. 1983. Learning and development through social interaction and conflict: A challenge to social learning theory. Piaget and the foundations of knowledge: 231–247.
Peter, C. 2008. Die Einwilligung von minderjährigen in medizinische eingriffe [Minors‘ consent in medical interventions]. Schweizerische Ärztezeitung 89(36): 1539–1540.
Peter, E., and J. Liaschenko. 2013. Moral distress reexamined: A feminist interpretation of nurses’ identities, relationships, and responsibilites. Journal of Bioethical Inquiry 10(3): 337–345.
Piaget, J. 1972. Intellectual evolution from adolescence to adulthood. Human Development 15(1): 1–12.
Rogoff, B., C. Mosier, J. Mistry, and A. Göncü. 1993. Toddlers’ guided participation with their caregivers in cultural activity. In Contexts for learning: Sociocultural dynamics in children’s development, ed. E.A. Forman, N. Minick, and C.A. Stone, 175–179. New York: Oxford University Press.
Ruhe, K.M., T. Wangmo, D.O. Badarau, B.S. Elger, and F. Niggli. 2014. Decision-making capacity of children and adolescents—Suggestions for advancing the concept’s implementation in pediatric healthcare. European Journal of Pediatrics 174(6): 1–8.
Sametz, L. 1979. Children, law and child development: The child developmentalist’s role in the legal system. Juvenile and Family Court Journal 30(3): 49–67.
Siegel, L.S. 1993. Amazing new discovery: Piaget was wrong! Canadian Psychology/Psychologie Canadienne 34(3): 239–245.
Siegel, L.S., and B. Hodkin. 1982. The garden path to the understanding of cognitive development: Has Piaget led us into the poison ivy? In Jean Piaget: Consensus and controversy, ed. S. Modgil and C. Modgil, 239–245. London: Holt, Rinehart & Winston.
Sjöstrand, M., S. Eriksson, N. Juth, and G. Helgesson. 2013. Paternalism in the name of autonomy. Journal of Medicine and Philosophy 38(6): 710–724.
Stier, S. 1978. Children’s rights and society's duties. Journal of Social Issues 34(2): 46–58.
Stoljar, N. 2013. Feminist perspectives on autonomy. Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/entries/feminism-autonomy/. Accessed December 6, 2014.
Tryphon, A., and J. Vonèche. 2013. Piaget Vygotsky: The social genesis of thought. New York: Psychology Press.
Vygotsky, L.S. 1978a. Interaction between learning and development. In Readings on the development of children, ed. M. Gauvain and M. Cole, 34–41. New York: W. H. Freeman and Company.
———. 1978b. Internalization of higher psychological functions. In Mind in society: The development of higher psychological processes, ed. M. Cole, V. John-Steiner, S. Scribner, and E. Souberman, 52–57. Cambridge, Massachussets: Harvard University Press.
———. 1986. Thought and language. Cambridge: The Massachusetts Institute of Technology.
Whitty-Rogers, J., M. Alex, C. MacDonald, D.P. Gallant, and W. Austin. 2009. Working with children in end-of-life decision making. Nursing Ethics 16(6): 743–758.
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Ruhe, K.M., De Clercq, E., Wangmo, T. et al. Relational Capacity: Broadening the Notion of Decision-Making Capacity in Paediatric Healthcare. Bioethical Inquiry 13, 515–524 (2016). https://doi.org/10.1007/s11673-016-9735-z
- Relational autonomy