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Abstract

This entry considers pediatric bioethics in a global context. Like any analysis of a global nature, many of the questions in pediatric bioethics globally – e.g., what constitutes legitimate agency, authority, decision-making, the role of family, and truth-telling – reﬂect the fundamental philosophical tension between universality and particularity in social and political theory. One question of global relevance that navigates this tension is the moral and legal status of the child, speciﬁcally, how changing conceptions of the child have led to a global normative understanding of the child as a moral agent in his or her own right. One striking feature of this understanding is the wide acceptance of two notions that have fundamentally altered – and arguably universalized – the status of the child: the best interests principle, which defends a view of the child as having interests, and the rights of the child, which recognize the child as rights bearer. While the best interests standard has been challenged for its indeterminacy, it remains relevant on account of the ﬂexibility that renders it applicable to a broad range of cultures. Thus, the indeterminacy of the best interests standard, it is argued, is both a strength and a limitation; and it is the strength of its indeterminacy that has led to its globalizing and localizing appeal.

Introduction

This entry considers pediatric bioethics in a global context. Like any analysis of a global nature, many of the questions in pediatric bioethics globally – e.g., what constitutes legitimate agency, authority, decision-making, the role of family, and truth-telling – reﬂect the fundamental philosophical tension between universality and particularity in social and political theory, a tension that moves between defending universal norms or standards, a universal ideal, and the idea that there are distinct, historically constituted cultures, of equal worth, a respect for the way of life of different cultural contexts. These questions resonate universally, yet how they play out in particular communities, with their particular traditions, varies considerably across the world and, thus, whether there are genuine universal norms that animate them is open to question. To consider pediatric bioethics globally, just like any question treated on a global scale, one must tread the difﬁcult path between universalizing (or “globalizing”) and relativizing (or “localizing”) principles.

One question of global relevance that navigates this tension is the moral and legal status of the child, speciﬁcally, how changing conceptions of the child have led to a global normative understanding of the child as a moral agent in his or her own right, a universal ideal that, in actual fact, takes on many different ﬂavors in different cultural settings. One striking feature of this global normative understanding is that there is wide acceptance of two notions that have fundamentally altered – and arguably universalized – the status of the child: the best interests principle, which defends a view of the child as having interests, and the rights of the child, which recognize the child as rights bearer. Yet while these notions are ﬁrmly entrenched in international conventions and law, thereby implying universality, their implementation is inextricably tied to each cultural context in which they are invoked. Best interests of the child have been described as the prevailing standard in pediatric decision-making (Kopelman 2010); and rights of the child have been steadily “elevated to the level of jus cogens” (i.e., fundamental, overriding principles from which derogation is not permitted) in international law (Strasburger 2013). Accordingly, an exploration of these concepts and their relationship to one another provides a window into pediatric bioethics globally through the lens of changing conceptions of the moral and legal status of the child.

This entry examines the historical reconceptualization of the child and how it has taken on universalizing features through the foundational notions of (1) best interests and (2) rights of the child. It then reviews the literature that brings them into dialogue by reﬂecting on the epistemological tensions between them. Despite the powerful appeal of rights, or what Kymlicka describes as a global “rights consciousness,” the best interests principle has remained a central threshold and is in fact a primary consideration in the United Nations Convention on the Rights of the Child (UNCRC), the most widely accepted source of the rights of the child. The grounds on which the best interests standard has been most challenged, its indeterminacy, are also the grounds that carry the most potential for utility on a global level – its ﬂexibility that renders it applicable to a broad range of cultures. Thus, the indeterminacy of the best interests standard, it is argued, is both a strength and a limitation; and it is the strength of its indeterminacy that has led to its globalizing and localizing appeal.

While this entry resists proposing an analysis that claims to derive from universalist principles of bioethics, there is no question that what has emerged as fundamental elements of pediatric bioethics globally privileges a liberal account of the child and of family dominant in Western thought and practices. Critiques of the best interests or rights-based discourses raise important questions for legitimate competing claims. As such, these concepts are not without controversy. Legal rights have been challenged as being insufﬁcient to transform the structured inequalities that shape global health, and a more substantive equality that takes account of social determinants of health is required to effect meaningful change. Similarly, the best interests standard has been challenged on various grounds as being insufﬁcient to guide decision-making. While both concepts have been critiqued for being inherently based on individualistic notions of agency and rationality, their importance cannot be underestimated. They inform the landscape of pediatrics globally. They have had profound implications for how we conceptualize the role of the child in health-care decision-making as a veritable actor, through the recognition of the child as a unique moral agent with rights.

Pediatric Bioethics

While there is no universally agreed-upon deﬁnition of pediatric bioethics, for the purposes of this entry, pediatric bioethics or the ethics of pediatric health care will refer to bringing the perspectives of all relevant parties and interdisciplinary considerations to addressing ethical issues in the health care of children. Relevant parties can include the child himself or herself, the child’s surrogate, or decision-makers, the health-care providers, and those taking on additional spiritual, advocacy, legal, or organizational roles. Interdisciplinary considerations can be analyses grounded in science, ethics, law, and where relevant the family’s religion or cultural norms.

Pediatric bioethics is grounded in an understanding of bioethics that recognizes (1) the centrality of the role of parents (or surrogates) acting in the best interests of the incapable child and (2) the developing autonomy of the pediatric patient recognized as a distinct moral agent with rights.

Traditionally, parents and physicians made health-care decisions pertaining to children without regard for the child’s views or preferences . Key to pediatric bioethics is the ways in which the formal status and the role of the child have evolved along three conceptual developments:

The paradigm shift from the child as property to the child as an object of protection that paved the way for the emergence of the best interests standard
The rise of autonomy which changed the nature of medical decision-making that leads to new ways of thinking about the developing autonomy of children and the role of children in decision-making
The emergence of the child as rights bearer and the institution of basic rights for children as articulated in the United Nations Convention on the Rights of the Child (UNCRC) (United Nations General Assembly 1989) that redeﬁned the child as an object of protection to an autonomous moral agent with rights

Best Interests Standard

From The Child As Property To Interests Of The Child

Historically, children were the property of men, bound to the economic, legal, and physical power of the father, who had the authority to make every decision for his children and choose how to treat them. Hobbes (1640) may have said it most starkly:

Children .. . are in the most absolute subjection to [their parents], that so bringeth them up, preserves them. And they may alienate them, that is assign his or her domination, by selling or giving them in adoption or servitude to others; or may pawn them for hostages, kill them for rebellion, or sacriﬁce them for peace, by the law of nature, when he or she, in his or her conscience, think that to be necessary.

The Industrial Revolution fundamentally challenged the view of the child as property in favor of a view of the child as having interests, in large part as a result of the separation of work and home that led to new conceptions of family and children. Children, and the notion of childhood, became central to the creation and ﬂourishing of family life, and, as they began losing “the economic value they had held” (Dolgin 1996) in agrarian economies, their economic role shifted from one of participation in production to one of consumption. In this dynamic, children’s interests became central in custody and parentage determinations, “displacing the once unyielding principle that always gave fathers custody of their children .. . [and] as fathers no longer had an economic incentive to retain custody of their children” (Dolgin 1996), mothers dominated the home and gained rights to custody.

The view of children as property, and of absolute paternal rights, gave way to the emergence of a new standard in child custody law that increasingly recognized the interests of the child. Parents no longer had the absolute authority to neglect, abuse, or endanger their children and were compelled to make decisions that served the interests of their children. As Kopelman explains: “The best interests standard was introduced to undercut policies that children (and other incompetent persons) were property of their guardians and to give children’s interests some weight” (2010). As such, the best interests standard was constructed in jurisprudence as a standard to provide for and protect children (Alston 1994; Dolgin 1996; Strasburger 2013). It gave children, and persons lacking capacity, legal rights to a minimal threshold of care.

Today, the best interests standard is entrenched in some form, and has been elevated to a principle, in many national and international legal systems and policy frameworks (e.g., African Charter on the Rights and Welfare of the Child (1990), European Convention on Human Rights (2010), UN High Commission for Refugees, on action for refugee children (2008)), and it has important analogues in many cultural, religious, or other traditions (Alston 1994). As Alston observes, “perhaps the strongest evidence of the extent to which the principle has gained general acceptance is the frequency with which it is used in legal analyses at the international level in general” (1994).

Predominant Standard

In bioethics discourse, the best interests standard appears to be the predominant standard of pediatric decision-making (Kopelman 2010; Salter 2012, 2014). Salter (2012) gives many examples where best interests are invoked in a pediatric context: the American Medical Association, in an opinion on pediatric decision-making (2006); the UK Mental Capacity Act (2005); and foundational bioethics and clinical ethics texts (see further reading Beauchamp and Childress 2008 and Jonsen et al. 2006). Appealing to the child’s best interests, however, does not provide uncontroversial rules or frameworks for determining what a child’s interests are, by whose standards, and to which standard of interests those choosing for the child should be held (Baines 2008). While it is frequently referred to in the medical, legal, and bioethics literature, the concept does not have a universally accepted definition (Kopelman 2010), and it is often presumed that those making health-care decisions for a child in a health-care context understand what it means to act in a child’s best interests (Salter 2012). Thus, appealing to the child’s best interests does not provide uncontroversial rules or frameworks for determining what a child’s interests are, by whose standards, and to which standard of interests those choosing for the child should be held (Baines 2008).

In law, for example, different interpretations of what constitutes best interests have been invoked to support conﬂicting outcomes or diametrically opposed conclusions (Salter 2012), especially through the lens of different cultural and legal interpretations. As a case in point, assumptions that have underpinned the application of the best interests standard have represented shifting social understandings of children and of the parent–child relationship (Dolgin 1996). In custody litigation, for example, assumptions that have directed applications of the best interests standard have been those that have favored “maternal custody,” custody with the “primary caretaker,” the “psycho logical parent,” the parent of the same gender as the child, the parent preferred by the child, and both parents jointly (Dolgin 1996). In the healthcare context, best interests have emphasized physical, emotional, and social interests. It has reﬂected among other values a commitment to life, quality of life, relationships, cultural identity, and respect of capable wishes.

Requiring What Is Ideal Versus What Is Reasonable

In bioethics scholarship, there are, according to Salter’s analysis (Salter 2012), six key interpretations of best interests whose “critical differences turn on the types of interests emphasized and prioritized” (Salter 2012), that is, what weight is accorded to self-and other-regarding interests.

A commonly invoked interpretation in bioethics scholarship calls on those making determinations of best interests to aim for what Kopelman (2010) describes as ideal: “The surrogate must try to determine the net beneﬁts to the patient of each option, after assigning weights reﬂecting the relative importance of various interests affected when subtracting the “cost” from the “beneﬁts” for each option” to achieve the “greatest net beneﬁt” (Buchanan and Brock 1989). As Salter explains: “This characterization is similar to other common interpretations of the standard in that it allows only certain interests into the decision-making calculus: the best interests determination should focus on the individual’s “self-regarding” interests” ( Salter 2012; citing Buchanan and Brock 1989). In this (ideal) view, the best interests standard is understood as an objective standard of decision-making that does not account for the preferences : of the individual or other interests tied to the child (Salter 2014) (e.g., the interests of other family members or of the family as a unit).

Opponents to the view of the best interests standard as requiring what is ideal (i.e., as an objective standard of decision-making) argue that the concept is too individualistic and thus “descriptively inaccurate” (Salter 2014). Like the dominant view of bioethics, according to Salter, it embodies a liberal individualistic view of the child; that is, the interests of the child and the child himself or herself are understood as independent from the interests of “intimate, related others on behalf of their child’s best interests.” Yet, Salter further argues, “we can’t be individualistic in pediatric decision-making because the basic structure of the decision-making standard won’t allow it” (Salter 2014). As such, understanding pediatric decision-making as guided by the best interests standard is both ontologically false – for children are necessarily dependent, encumbered, and in relationship – and normatively dangerous (for it promotes the idea that the ideal moral agent is fully independent) (Salter 2014).

Kopelman agrees that the view of the best interests standard as requiring what is ideal is too individualistic. But, she argues, “it is a mistake to conclude that it is excessively individualistic and excludes all other people’s interests other than the needs of the patient. This standard would be incoherent and self-defeating if it required the best for everyone” (Kopelman 2010). Viewing the best interests standard as always requiring what is ideal necessarily calls for what is at times impossible and “is divorced” (2010) from the historical context in which it arose and how it ought to be used in practice. She states, “when we consider how this standard is used to solve practical problems, however, it does not require what is ideal but what is reasonable.” To that end, she proposes a relational view of the best interests standard, that of requiring what is reasonable, deﬁned by three conditions, to render it a viable decision-making standard: (1) the prima facie duty of decision makers to maximize the person’s overall or long-term beneﬁts and minimize burdens, (2) the condition to meet a minimum threshold of acceptable care, and (3) the condition to make choices compatible with established moral and legal duties to persons lacking decision-making capacity.

Even on the view that the best interests standard requires what is reasonable, and not necessarily what is ideal, many have argued that the child’s best interests are today often understood in terms of “the child’s equality and liberty interests” (Cherry 2010), a view itself underpinned by the idea that the rational goal when making decisions involving children is to develop a child’s independence or his or her capacity for autonomous self-determination. The catalyst for this view was the recognition of the developing autonomy of the child and his or her increased role and responsibility in making decisions about his or her care.

The Developing Autonomy Of The Child

Two key changes have contributed to the involvement of children, and how children are involved, in health-care decision-making (Kenny et al. 2008) in contexts where autonomy is thought to be essential: (1) The recognition that children have evolving, and dramatically differing levels of, decisional maturity or capacity along a continuum that ranges from those that lack decisional capacity, those with developing decisional capacity, and those with developed capacity. (2) Support for the three categories of decisional capacity and the different levels of inclusion of children in treatment decisions became the norm: from the requirement of parental consent for those lacking decisional capacity (usually infants) to expectations of parental consent, child assent for those with developing capacity, and the child’s consent for those with developed capacity (usually adolescents).

Kenny et al. explain that “assent refers to an agreement with a decision or course of action as distinct from consent, which refers to an informed and voluntary choice with respect to a decision or course of action.” They continue by explaining that “assent was said to demonstrate respect for the child’s developing autonomy, and parental consent/permission was said to protect the child from assuming unreasonable risks” (2008). The question of assent, e.g., what constitutes assent and when are conditions to gain assent satisﬁed, has been both further advanced and challenged on theoretical and practical grounds. Signiﬁcantly, however, the view that medical decision-making involving children moves along a trajectory from assent to consent, according to an understanding of the developing capacity of the child, has become an important part of the fabric of the bioethics of pediatric decision-making.

The view of the child as an active participant in making decisions about his or her care was furthered by the conceptualization of the child as rights bearer which effectively reconceptualized the status of the child and expectations around health-care decision-making for and involving children.

Rights Of The Child

The Child As Rights Bearer

A multifaceted and international discourse on children’s rights (Freeman 1993) evolved into the recognition that children have inherent rights, thereby setting the stage for their articulation in the United Nations Convention on the Rights of the Child (UNCRC). Not coincidentally, the UNCRC was ratiﬁed in the International Year of the Child (1989), creating international rights of the child and providing principles guiding States’ laws and practices involving children.

The modern view that the child bears rights galvanized the reconceptualization of the child as an autonomous and self-determining agent capable of choice, a view ﬁrmly grounded in the dominant liberal view that every individual is an autonomous rational agent who has the authority and ability to make appropriate choices for his or her own sake. Mama summarizes both the philosophical view of the child as an autonomous self-possessed moral agent bearing rights and how that view is embodied in the UNCRC (Mama 2009):

Accept that children are people now – not people in the making. This accords all children full human status from birth.
Accept that childhood is valuable in its own right and is not simply a stage toward adulthood.
Accept that children can be active agents of their own lives.
Accept that children should not be treated less seriously just because of their age.
Address the special vulnerability of infants and children.

In short, the child is not an adult-in-the-making, or a becoming, but a being with inherent moral worth who has the right, and the evolving capacity, to make conscious life choices.

Central to the UNCRC is that the best interests of the child remain “a primary consideration” (United Nations General Assembly, 1989, Art 3(1)) in what is arguably the “most detailed and comprehensive international human rights instrument (in terms of the rights recognized, as opposed to the categories of persons covered)” (Alston 1994). While many international conventions accord rights to children (e.g., International Convention on the Elimination of All Forms of Racial Discrimination, Convention on the Rights of Persons with Disabilities), we focus on the UNCRC because it is “perhaps one of the most inﬂuential documents to ascribe to a best-interests doctrine” (Salter 2012), a notion central to the reconceptualization of the status and role of the child and pediatric bioethics.

The Best Interests Principle Within The UNCRC

The best interests principle is one of the four general principles of the UNCRC, alongside protection, provision, and participation. As such, while the UNCRC was designed to create international rights for children, it affords both rights to and interests for children (Strasburger 2013). Art 3(1) of the UNCRC stipulates that “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.” It mandates three kinds of action: “one proposing the principle, one charging the State with enforcing the principle with respect to the child’s guardians, and one charging the State with enforcing the principle with respect to State actions” (Strasburger 2013).

Signiﬁcantly, the best interests principle appears to serve three, qualitatively different, functions in the UNCRC, as (1) a means to “support, justify or clarify a particular approach to issues arising under the Convention … as an element which needs to be taken fully into account in implementing other rights; (2) a mediating principle to resolve conﬂict arising between different rights in the Convention (Alston 1994); and (3) a basis for evaluating State laws and practices not governed by the rights of the Convention” (Alston 1994).

Reinforcing its centrality, the concept of best interests appears in several other sections of the Convention: in relation to the separation of the child from the family setting (Art 9), with reference to parental responsibility for the upbringing and development of the child (Art 18), in relation to adoption and comparable practices (Arts 20 and 21), and in the context of the child’s involvement with the police and justice system (Arts 37 and 40) (Alston 1994).

Many have observed, and criticized, that the UNCRC does not explicitly deﬁne what constitutes, or what factors determine, or what weight should be given to the principle of the best interests of the child. This has continued to fuel the underlying debate surrounding the indeterminacy of the principle. What is made clear, however, is that within the UNCRC framework, it is not parents who are accountable for ensuring that the best interests of the child are considered when making decisions involving children; the obligation to ensure that the best interests of the child are served when in the care of his or her parents is upon the State, who is required to “determine if an act of the parents … is in the best interest of the child” (Strasburger 2013). This may undermine, too detrimentally Cherry (2010) posits, the authority of parents, a view that bears signiﬁcant impact on pediatric decision-making.

On the other hand, and what is plausibly in contradiction, the UNCRC clearly afﬁrms that family responsibilities and duties, and the rights of parents to raise their children, should be respected. This raises important questions central to both pediatric bioethics and the application of the UNCRC about the role of culture, what constitutes a family, what authority parents have over their children, who is in authority, and what or whether there are limits to that authority (Iltis 2010).

Pediatric Bioethical Decision-Making

Significance Of Children’s Rights For Pediatric Decision-Making

Questions arising from the UNCRC about the role and authority of parents and of the family have been raised in the context of the scholarship on pediatric decision-making (Cherry 2010; Engelhardt 2010; Iltis 2010). These caution against adopting the framework of the UNCRC because it does not adequately give weight to the central role of family (Cherry 2010), or articulate foundational premises of what constitutes the family (Engelhardt 2010), or specify normative criteria to inform decisions about what constitutes the best interests of the child (Iltis 2010).

One such view is that the UNCRC undermines the traditional (moral and social) role of the authority of parents in pediatric bioethical decision-making (Cherry 2010). Speciﬁcally, it reduces the role of parents “to acting as custodians of the best interests of children” because the child necessarily holds rights “independently of their parents and are enforceable by children over against their parents through the medium of the state” (Cherry 2010). Echoing a common view (e.g., Iltis 2010; Salter 2014), Cherry reproaches the UNCRC for being too deeply individualistic because it creates rights that emphasize and promote a view of the child’s best interests in terms of “the child’s equality and liberty interests” (Cherry 2010). In so doing, it articulates a vision that “perhaps inadvertently, drives a legal and moral” gulf between parents and their own children (Cherry 2010). Such a vision, argues Cherry, does not support the conditions necessary for the family to adequately function, and act in the child’s best interests, as a moral community. Thus, by presupposing the primacy of human rights, and recasting the child as outside the sphere of the moral authority of his or her family, such a vision acts in tension with many pediatric bioethical decision-making frameworks largely determined by “family-oriented moral and political commitments,” shaped within particular religious and cultural understandings (Cherry 2010) that may or may not recognize rights as having legitimacy.

Engelhardt argues that the conﬂict between parental authority and the aspirations of the UNCRC extends beyond the issue that it gives priority to the child’s equality and liberty rights-based interests. It requires a questioning of whether the priority given to rights is in the child’s best interests in the ﬁrst instance, a construct posited without justiﬁcation in the UNCRC. According to Engelhardt, the recasting of the scope and character of parental authority, “by not recognizing parents as an authority over their children, save as trustees of their children’s best interests” (Engelhardt 2010), fundamentally alters many conceptions of the nature of family. It embodies a “post-traditional vision” that seeks “to anchor social institutions, including the family, in concerns for liberty and equality, as well as in terms of a libertarian focus on the emerging autonomy of the child” (Engelhardt 2010), a vision that is fundamentally at odds with other understandings of the moral signiﬁcance of the family. But more than that, it does not recognize that there are foundationally incompatible views of the moral status of the family in most contemporary societies that are “at the heart of culture wars [that] have substantive implications for the bioethics of pediatric decision-making” (Engelhardt 2010). Engelhardt identiﬁes four accounts of “the moral and ontological standing of the family that underlie conﬂicting views of the child’s status” (Engelhardt 2010) and the role of family in pediatric decision-making. Each account – sociobiological, categorical, liberal social constructivist, and libertarian social constructivist – refers to

a different appreciation of familial integrity, sovereignty, and authority, as well as of the nature of parental authority, the relationship between men and women in the founding of families, the status of children (.. .) the proper relation of children to parental authority and therefore the place of children in pediatric decision-making. (Engelhardt 2010)

These views of the nature of family are grounded in “robustly developed and conﬂicting worldviews supported by disparate basic premises about the nature of morality” (Engelhardt 2010) that are irreconcilable and intractable. Any attempt, therefore, to forge a global consensus on the status of the child or the moral signiﬁcance of the family and its bearing on pediatric bioethical decision-making is rendered impossible.

The Indeterminacy Of The Best Interests Standard

Alston offers a different view: The UNCRC does not mandate a particular vision or purport to reﬂect international convergence on the status of the child. He observes that it

is sometimes presented (or, more accurately, misrepresented) as being a uni-dimensional document that reﬂects a single, uniﬁed philosophy of children’s rights and contains a speciﬁc and readily ascertainable recipe for resolving the inevitable tensions and conﬂicts that arise in a given situation among the different rights recognized. Similarly the respective entitlements of the different actors involved, included the child, the parents, the family, the extended family, the local community, the society and the State are assumed to be clearly deﬁned and delineated .. . In fact, the Convention is far more complex and multi-dimensional than any characterizations would imply. (1994)

He emphasizes the extent to which the actual content of the UNCRC, in particular the best interests principle, is inextricably tied to “the cultural context in which it is invoked” (Alston 1994). Indeed, to reach convergence, and perhaps as a kind of built-in safeguard against universalizing how children ought to be treated, a duty was placed on signatory States to respect local customary practices, further bolstered by the preamble that takes “due account of the importance of the traditions and cultural values of each people for the protection and harmonious development of the child.” This is an important consideration. While some have interpreted the acknowledgment of the role of culture in the development of a child as an implicit acknowledgment that “the child’s welfare may well be ‘trumped’ at times by ‘cultural values and traditions’” (Freeman 1993), a broader view has been to examine the assertion of culture in the context of the UNCRC’s emphasis on the importance of family to raising, and how one views the proper way to raise, children.

A still broader conceptual view has been to examine the assertion of culture in the UNCRC in the context of the broader relationship between culture and human rights (Alston 1994). In Alston’s view, the best interests principle as reﬂected in the UNCRC acts as a window on the relationship between culture and human rights; it provides insights on how it may be possible to bridge the schism between culture and human rights and respond to criticisms that have been leveled at the “universalist aspirations of human rights law” (Alston 1994). Notably, he observes that the indeterminacy of children’s rights norms, indeed a fundamental characteristic of all human rights norms, is not necessarily a limitation. For any arrangement involving “the relationship between the state, the family and the child, must be characterized by a signiﬁcant degree of ﬂexibility and adaptability.” He explains: “If human rights norms in general can be said to be inherently indeterminate, the best interests principle is located by most of its critics at the most indeterminate outer margins even of that body of norms” (Alston 1994). In fact, the drafters of the UNCRC “seem to have been unaware of the controversy over the principle and thus felt no need to defend its open-endedness or to propose elements which might inject some particular content to it” (Alston 1994). But this indeterminacy plays a positive role: “it serves to emphasize the importance of both institutions as a means through which to develop a better understanding of the different cultural dimensions of the relevant norms” (Alston 1994).

No doubt, any application of the best interests standard raises difﬁcult questions about what constitutes a child’s “interests” and what counts as “best.” This question looms large in pediatric bioethics. Many have argued that the standard is rendered indeterminate on a practical level because it is too ambiguous to provide an objective basis for decision-making (Dolgin 1996). Indeed, it does not, as Iltis (2010) argues, articulate fundamental moral assumptions or “establish who is in authority to determine the fundamental moral assumptions that will inform the principles and norms that govern decisions.” Yet, according to Dolgin (1996), the indeterminacy of the best interests standard is precisely why it has survived and ﬂourished. She explains:

Only because the principle is so broad has it been able to serve this end. In this regard, its limitations for the law (its indeterminacy) has been its beneﬁt for the law (its adaptability) .. . The principle, precisely because of its indeterminacy, has been ﬂexible enough to justify shifting social preferences and to reﬂect changing visions of the family without requiring an express alteration in the rule of law.

In effect, the strength of the philosophical and practical appeal of the best interests standard has rendered it foundational in law and health-care decisions involving children despite, or perhaps because of, its indeterminacy, which may reasonably be viewed as both a limitation and a strength allowing for ﬂexibility in (cultural) interpretation and application. As Alston ponders: “While it is most commonly argued in liberal societies that the child’s best interests are obviously best served by policies that preserve or promote individual autonomy, the bests interests of the child in more traditional societies might be interpreted as requiring the sublimation of the individual child’s preferences and views to the interests of the family (and extended family)” (Alston 1994). Similarly, Solnit (2004) emphasizes that what he calls the bioethics of children’s rights is necessarily embedded in the laws and policies of a society and in the values, customs, and practices of the culture that shape them. In short, while the best interests standard may be widely invoked, it is open to different interpretations in different settings.

But there is an important caveat. The best interests principle as reﬂected in the UNCRC is both informed and constrained by the rights (Strasburger 2013), meaning that it is an important consideration – “an umbrella provision” (Alston 1994) – when implementing the rights, yet it cannot violate a right. In this way, there is what might be considered a reasonableness standard, which is to say that there are vitally important and inviolable standards, and while there are legitimate competing claims, not everything is equally defensible. Changing conceptions of the moral and legal status of the child have led to a global normative understanding of the child as a moral agent in his or her own right, an understanding that both underpins and permeates medical, legal, and policy decisions involving children, globally.

Disharmony between available international frameworks and worldviews opposed to these can raise moral and legal tensions. In the context of pediatric health care, work in global pediatric bioethics is a step in the right direction. Its values of acting in a child’s best interests, respecting relevant voices and engaging diverse perspectives through the tools of multiple disciplines, seem to be a formula warranting cautious optimism.

Conclusion

The goal of this entry was to consider pediatric bioethics within a global context. The value of doing so is to appreciate the relevance of pediatric bioethics around the globe as well as locally. The health care of children commonly involves contexts where patients, families, and health-care providers come to the health-care encounter with a range of differing and consistent values. Varied interpretations of concepts as seemingly supported as best interests should be expected in most pediatric health-care contexts. Values foundational to pediatric bioethics may be deﬁned or resonate differently around the world. The pediatric bioethics goal of sustained moral peace in the health care of children – generated through the perspectives of relevant parties and interdisciplinary considerations – seems consistent with best interests and child rights frameworks. Consideration of the concept of best interests, in relation to international frameworks for child rights, provides a window into the nascent ﬁeld of pediatric global bioethics.

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