Best Interest Standard in School Health: A Concept Analysis

The bioethical concept of best interest standard is cited in courts across America and considered to be an effective method of managing pediatric health care decision-making. Although the best interest standard is referred to in an abundance of nursing, medical, legal, and bioethical literature, refinement and a clear definition of the concept are lacking in the context of school health. An exhaustive and methodical search was conducted across six databases revealing 41 articles from the past decade. The Wilsonian methodology was used to analyze, refine, and clarify the concept of best interest standard by presenting original case vignettes (model, contrary, related, and borderline) and an innovative conceptual model as it applies to school nursing. This concept analysis provides school nurses with a deeper understanding of the best interest standard to navigate the complex nature of making school health care decisions.

Problems with Doctors Invoking the Best Interest Standard

Although the “best interest standard” has been widely accepted as a benchmark for decisions made on behalf of others, this chapter explains why medical professionals should eschew the phrase. Decisions by medical professionals are different from decisions by patients and surrogates, and their duty to care for patients and promote their interests is markedly different from acting in the patient’s best interest. Doctors must distinguish their professional fiduciary responsibilities from the concept of best interest because confusing the two can lead to blunders with unfortunate consequences. This chapter responds to supporters of the best interest standard, like Kopelman, and critics, like Veatch, who object to its being subjective and vague. It also explains why introducing the phrase into the language of medical professionals can be misleading or irrelevant and lead to behavior that is intolerant, polarizing, and unjust. Instead, the chapter offers the “three-box model” for guiding doctors’ responses to surrogate decisions.

Surrogate decision making for unrepresented patients: Proposing a harm reduction interpretation of the best interest standard

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that standard applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust.

Whose Decision Is This?

Decision-making in palliative and end-of-life care can be difficult to navigate. This is even more so in pediatric palliative and end of life care when parents may disagree with each other or for teenagers who are not yet legally able to make their own medical decisions. Surrogate decision making can also complicate end of life decision making in pediatrics. To navigate these complex situations, the best interest standard, harm principle, and other standards are often applied when concerns arise over surrogate decision-making. This chapter presents a discussion of the ethical principles and a recommended approach to managing clinical situations with uncertain or conflicting surrogate decision-makers.

Child Custody, Visitation, and Support

One of the most contentious, and recently evolving, components of a divorce agreement involves custody of the children. And, this area of family law has been particularly influenced by psychology and other social science research. The guiding principle is that of the best interest standard, which requires an inquiry that goes beyond concrete legal rules that relies on psychological principles and often introduces psychological experts into the legal setting. Those experts can aid with custody arrangements and understanding the potential impact of the divorce on the children. Legal rules define and provide guidelines for financial child support. Finally, newer areas within the law of custody focus on grandparent involvement in their grandchildren’s lives and the newer area within family law of pet custody.

‘My child, my choice’: parents, doctors and the ethical standards for resolving their disagreement

Disagreements between doctors and parents as to the appropriate treatment of a child have been exacerbated by a number of recent developments, especially the use of the internet. In normative terms there has been a popular assertion of a parent’s right to choose the treatment of his or her child and this has been defended in the bioethics literature, often in the context of a preference for a harm over a best interests principle for adjudicating these differences. This article affirms the centrality of a best interest standard and criticises arguments for giving parental views a certain moral weight based upon the view that parents know best, or on the interests of the parents, or as consistent with the use of child protection principles, or in value uncertainty.

The best interest standard and children: clarifying a concept and responding to its critics

This work clarifies the role of the best interest standard (BIS) as ethical principle in the medical care of children. It relates the BIS to the ethical framework of medical practice. The BIS is shown to be a general principle in medical ethics, providing grounding to prima facie obligations. The foundational BIS of Kopelman and Buchanan and Brock are reviewed and shown to be in agreement with the BIS here defended. Critics describe the BIS as being too demanding, narrow, opaque, not taking the family into account and not suitable as limiting principle. This work responds to these criticisms, showing that they do not stand up to scrutiny. They either do not apply to the BIS, only apply to misuses of the BIS or criticise a BIS that is not seriously defended in the literature.