The Cambridge textbook of bioethics

124N. Kenny, J. Downie, and C. Harrison

child’s best interests. For example, courts have deemed children to be in need of protection and placed them under the care and control of child and family services and courts have themselves ordered blood transfusions in cases in which parents who are Jehovah’s Witnesses refuse life-saving transfusions for their children.

Policy

Professional bodies with obligations and duties to children have formally recognized this new and emerging attention to the respectful involvement of children and youth in medical decisions. For example, the Canadian Paediatric Society policy on treatment decisions regarding infants, children, and adolescents states that ‘‘to ensure that the best decisions are made for children and adolescents, these decisions should be made jointly by members of the healthcare team, the parents of the child or adolescent, and sometimes the child or adolescent. Children and adolescents should be involved in decision-making to an increasing degree as they develop, until they are capable of making their own decisions about treatment’’ (Canadian Paediatric Society and Bioethics Committee, 2004, p. 99). The American Academy of Pediatrics (1995, p. 314) statement identifies the joint responsibility of physicians and parents to make decisions for very young patients in their best interest and states that ‘‘[p]arents and physicians should not exclude children and adolescents from decision-making without persuasive reasons.’’

Empirical studies

There is a body of empirical research providing some information on the competence of children for assent and consent (Abramovitch et al., 1995). Miller et al. (2004) have reviewed the empirical literature focusing on the voluntariness and competence of children for medical decisions. This review identified several fundamental dilemmas underlying current approaches to children’s consent, demonstrating the differences between a legal

(all-or-none) and a psychological (developmental, context dependent, and interactional) perspective; differences between the clinical and research settings; and differences in studies focusing on who makes the decision in contrast to those focusing on which decision is in the child’s best interest. They conclude that more research is needed in this area, with particular attention to be paid to the differences between the respectful involvement of the child in clinical and research decisions, examination of the noncognitive aspects of children’s competence, and the importance of context in the development of decisional capacity.

How should healthcare professionals respectfully involve a child in medical decision making in practice?

Healthcare professionals working with children should be sensitive to the particular capacities of each child. Children are constantly developing with respect to their physical, intellectual, emotional, and personal maturity. Although developmental milestones give us a general sense of capacities, there is no bright-line of a particular age that will indicate ability to participate in independent decision making.

Where it is determined that it would not harm the child to be involved in the parental decision making and where there is sufficient language capacity to engage the child, healthcare professionals should discuss the treatment options with the child. Healthcare professionals should seek the child’s opinion about the potential benefits and harms of the various options. Then, when assessing what action is in the best interests of the child, they should include a consideration of:

the potential harm of having something done to you that you do not want done (e.g., frustration, loss of trust in healthcare providers, loss of trust in family)

the potential harms and benefits to the child of the various options from the child’s perspective

as well as the perspectives of the healthcare providers and family members

the potential harms and benefits to the child’s family members and any others that the child’s interests are bound up with.

Once the substitute decision maker has made the decision (likely the parents), the healthcare professionals should carefully explain to the child, at an appropriate level and with the family’s assistance, what is going to happen to him or her.

The case

For H, resuming aggressive treatment will have a serious negative effect on her quality of life. The chances of remission are small, yet a decision to discontinue treatment will likely result in her death. Because death is irreversible, and decisions with serious consequences require a high level of competence in decision making, the capacity required for this treatment decision is very high. It has been determined that H does not have this decisional capacity and that her parents are her substitute decision makers.

Nevertheless, H is included in discussions about the treatment options and her reasons for not wanting treatment are explored. Members of the team work hard to re-establish trust. Discussions address the hopes and fears of H and her parents, the parents’ understanding of the possibility of cure, the meaning for them of the statistics provided by the physicians, as well as H’s role in the decision-making process and her access to information. Members of the team include physicians, nurses, a child psychologist, a psychiatrist, a member of the clergy, a bioethicist, a social worker, and a palliative care specialist.

Discussions focus on reaching a common understanding about the goals of treatment for H. Her physician helps her to express her feelings and concerns about the likely effects of continued treatment. Consideration is given to the effects on her physical well-being, quality of life, self-esteem, and dignity of imposing treatment against her

Involving the child in decision making 125

wishes. Spiritual and psychological support for H and her family is acknowledged to be an essential component of the treatment plan. Opportunities are provided for H and her family to speak to others who have had similar experiences, and staff are given the opportunity to voice their concerns.

Ultimately, a decision is made by H’s parents to refuse chemotherapy and the goal of treatment shifts from ‘‘cure’’ to ‘‘care.’’ H’s caregivers assure her and her family that they are not ‘‘giving up’’ but are directing their efforts toward H’s physical comfort and her spiritual and psychological needs. H returns home, supported by a community palliative care program, and is allowed to have a new kitten. She dies peacefully.

The healthcare team met after H’s death to review her care. They acknowledged that some parents might have made a different decision and discussed what their plan would be should this arise in future. This would include discussions among team members and with the parents to seek consensus about the potential for benefit to the patient, ongoing communication with the parents to ensure mutual understanding of the realistic goals of treatment, and psychosocial and emotional support of the patient during his or her course of treatment. It was acknowledged that in a situation such as H’s, her parents’ wishes for treatment would take precedence over her dissent. The team did not agree what their approach would be in situations where treatment would not be predicted to have a chance of remission of less than 20%. Some argued that they should refuse to provide treatment in such circumstances. Others argued that, even then, the parents’ decision should be respected. It was agreed that should the situation arise they would invite the hospital ethics team to assist with decision making and conflict resolution.

REF EREN CES

Abramovitch, R., Freedman, J. L., Henry, K., and Van Brunschot, M. (1995). Children’s capacity to agree to

psychological research: knowledge of risks and benefits and voluntariness. Ethics and Behaviour 5: 25–48.

American Academy of Pediatrics (1995). Informed consent, parental permission and assent in pediatric practice. Pediatrics 95: 314–17.

Baylis, F., Downie, J., and Kenny, N. P. (1999). Children and decisionmaking in health research. IRB: Rev Hum Subject Res 21: 5–10.

Bulford, R. (1997). Children have rights too. BMJ 314: 1421–2. Canadian Paediatric Society and Bioethics Committee (2004). Treatment decisions regarding infants, children

and adolescents. Paediatr Child Health 9: 99–103. Committee on Pediatric Emergency Medicine, AAP Policy,

and American Academy of Pediatrics (2003). Consent for emergency medical services for children and adolescents. Pediatrics 111: 703–6.

Kenny, N. P. and Skinner, L. E. (2003). Skills for assessing the appropriate role for children in health decisions. In Pediatric Clinical Skills, 3rd edn, ed. R. Goldbloom. New York: Saunders, pp. 349–59.

Miller, V. A., Drotor, D., and Kodish, E. (2004). Children’s competence for assent and consent: a review of empirical findings. Ethics Behav 14: 255–95.

Nelson, H. L. and Nelson, J. L. (1995). The Patient in the Family: An Ethics of Medicine and Families. New York: Routledge.

Rossi, W. C., Reynolds, W., and Nelson, R. M. (2003). Child assent and parental permission in pediatric research.

Theor Med Bioethics 24: 131–48.

Simpson, C. (2003). Children and research participation: who makes what decisions. Health Law Rev 11: 20–9.

Various authors (2003). Am J Bioethics 3: issue 4.

A five-year-old boy who has acute lymphoblastic leukemia was originally treated with combination chemotherapy and achieved remission. Within several months his disease relapsed. His doctors have determined that allogenic bone marrow transplantation offers the greatest chance of a sustained remission. His one-year-old sister is the best match. Their mother has agreed to the sister being a donor, but their father has reservations about putting her through the procedure and suggests that his wife, although not quite as good a match, should be the donor.

What are non-therapeutic pediatric interventions?

Non-therapeutic pediatric interventions, such as harvesting a child’s bone marrow, are medical interventions that are not intended to benefit medically the child upon whom they are performed. Therefore, where such interventions are proposed or undertaken, they have some other purpose. In the case opening this chapter, the purpose of harvesting J’s bone marrow is to save the life of I.

The word ‘‘therapeutic’’ can be understood in broader and narrower ways. In the narrower sense, it excludes prophylactic interventions – namely those that are not intended to cure some condition the child currently has but to prevent an adverse medical condition later. Because prophylactic interventions are morally similar (even if not identical) to narrowly therapeutic ones, I shall group these together and thus use ‘‘therapeutic’’ in the broader sense that includes prophylactic

measures. Non-therapeutic interventions are then those that neither cure nor prevent disease or impairment in those on whom they are performed.

The distinction between therapeutic and nontherapeutic interventions, although clear in theory, is far from clear in practice. This is because it is often a matter of dispute whether an intervention has therapeutic value. In other words, it is often unclear whether an intervention constitutes a net medical benefit to a child. For example, consider male circumcision that is not therapeutic in the narrow sense of curing an existing condition (such as true phimosis). There is considerable disagreement about whether such circumcision is an effective prophylactic measure. Some maintain that circumcision has considerable protective value against urinary tract infection, sexually transmitted diseases, and penile cancer. Others deny that it has any such value. Similar disagreements arise in connection with more radical interventions. For instance, some maintain that surgically assigning some intersex children to one sex or separating some conjoined twins is in those children’s interests. Others deny that these children are benefited by such procedures. I shall refer to all these types of intervention as interventions of disputed therapeutic value.

The word ‘‘pediatric,’’ like the word ‘‘therapeutic,’’ can be understood in narrower and broader ways. It can be used more restrictively to refer only to (prepubescent) children or more expansively to include adolescents. I shall use the term in a broader (but not the broadest) sense. This

128D. Benatar

is because what is important, from an ethical perspective, is to refer to those young people who are insufficiently developed to be competent to make judgements for themselves about whether the intervention should be performed. These include children and younger adolescents, but probably not the oldest adolescents. Competence is a matter of degree and so there is no sharp divide between children and early adolescence. Moreover, there are important distinctions to be drawn within childhood. For example, very young children – infants – have no ability whatsoever to decide for themselves whereas older pre-teens have some capacity to do so. Decision making on their behalf needs to take these developmental stages into account.

Why are non-therapeutic pediatric interventions important?

Non-therapeutic pediatric interventions pose a moral problem because they fall beyond the bounds of the only widely uncontested condition for medical intervention in the lives of those who are unable to consent to medical interventions – namely the therapeutic condition. Generally, in the case of competent people, their consent is a necessary moral condition for medical intervention. Children are not competent to decide which medical interventions may be performed on them and are, consequently, unable to provide valid consent. The absence of this consent, however, does not render all pediatric interventions problematic. It is widely agreed that some form of paternalism towards those who are not competent to make decisions for themselves is at least permissible and usually required. Following this principle of paternalism, pediatric interventions may or must be performed if they are to the child’s benefit. Therapeutic interventions clearly fall into this category. However, the paternalistic justification for intervention does not seem to apply to those pediatric interventions that are not (clearly) therapeutic. May such interventions ever be undertaken and, if so, when?

Consider first interventions that are of disputed therapeutic value. What is one to do in such circumstances of uncertainty? To intervene may impose a needless risk or harm if there happens to be no net benefit. However, acting on the principle of ‘‘primum non nocere’’ (‘‘first do no harm’’) would oversimplify matters, because to fail to intervene may be to withhold an important benefit if the intervention happens to be positively efficacious.

A vital question to ask in such circumstances is whether the uncertainty is a result of one’s own ignorance about the best available evidence or whether the best available evidence requires uncertainty. Doctors are often ignorant (or insufficiently critical) of the evidence for or against the purported therapeutic effect of some intervention. They operate on the basis of impression, anecdotal evidence, or received wisdom rather than carefully tracking down the primary data or even reliable reviews. However, sometimes a full inquiry into these matters reveals that the evidence is inconclusive and that agnosticism is the appropriate response. In such cases, there is no clear side of caution on which to err, and reasonable people might disagree about whether to undertake the intervention even if it is believed that therapeutic interventions are the only permissible ones in the pediatric context.

Disagreement about the therapeutic value of an intervention is not always attributable to uncertainty about the medical evidence. Sometimes, the disagreement is at least partly a disagreement about values. For example, some might judge a very small chance of death following circumcision in infancy to be less bad than an equally small chance of death from penile cancer at an older age, while others may hold the opposite view. Some might believe that a life spent joined to one’s twin is worse than death, while others might deny that it is bad at all. The presence of such disagreements does not mean that all competing views are always equally good. Sometimes, there may be better arguments for one evaluation than for the other. For this reason, the arguments for the competing

views should be explored. However, such exploration may reveal that the arguments for one view are not clearly stronger than the arguments for a competing view. In such cases, reasonable people can disagree: some taking a given intervention to be therapeutic while others deny that it is so.

The fitting response to reasonable disagreement about the therapeutic value of an intervention is to judge both the intervention and its avoidance permissible. If this is so, then even those who believe that the only pediatric interventions that are permissible are therapeutic ones must acknowledge that interventions they personally do not judge to be therapeutic should be permissible if others can reasonably regard them to be so.

More controversial than interventions of disputed therapeutic value are those that are performed in order to benefit somebody other than the child on whom they are performed. Consider, for example, research on children. Although children upon whom research is performed may sometimes stand to benefit from the intervention being tested, they may also be harmed by it. The main beneficiaries of the research are future children, who will either benefit from a proven effective intervention or be spared an intervention that at best is useless and at worst harmful. Other interventions, such as bone marrow transplantation from a child to a close family member, provide more certain benefits to others. Such interventions expose the (donor) child to some risk and harm without aiming to benefit that child medically.

Some people maintain that no such nontherapeutic pediatric intervention is permissible. In making this claim, they might appeal to the difference between a competent person agreeing to incur a risk or be harmed in order to benefit another and a second party authorizing such risk or harm for a being, such as a child, who has never been competent. However, we can acknowledge this difference without thinking that the latter authorizations are never permissible. One might think that authorizations for children may be made only below a lower threshold of risk or harm. It would surely be implausible to judge as

impermissible parents’ authorizing one of their children to be a blood donor for another of their children. The costs to the child of blood donation are clearly very minor and the benefits to the recipient clearly sufficiently great to justify such an intervention. Thus we see that an intervention cannot be ruled out simply because it is not therapeutic (for that child). We have to consider how big a risk or cost the intervention involves and how much good it can be expected to do others.

A second consideration that may be adduced in favor of at least some non-therapeutic interventions is that, although they may not benefit the child medically, some of them may benefit the child in other ways. If a child’s parent, for example, will likely die without a bone marrow transplant for which the child is the most suitable donor, it may be quite plausible to say that the child would be benefited, all things considered, by donating the bone marrow. The child may be harmed more by the loss of the parent than, for example, by the pain attendant upon harvesting of bone marrow.

How should I approach non-therapeutic pediatric interventions in practice?

Although doctors often recommend pediatric interventions, they are rarely ethically or legally entitled to make the decision that the intervention will be performed on a given child. Authority to make that decision is usually borne by the parents, who are the presumptive surrogate decision makers. However, the presumption that the parents have this authority may sometimes be defeated. In such cases, doctors and others, including sometimes the courts, may or must assume decision-making responsibility. Doctors usually have more power to refuse an intervention than they have power to authorize an intervention. If a parent authorizes an intervention that the doctor believes is clearly unreasonable, the doctor may usually refuse to perform it.

However, whether doctors are working in concert with or in opposition to parents, the underlying

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practical question that doctors, parents, and others should be asking is how one decides whether an intervention of disputed therapeutic value or of medical benefit only to others should be performed? One helpful decision procedure would be to ask the following series of questions. (i) Is the benefit to self or others greater than the risk or harm? (ii) Is the harm or risk excessive? (iii) Does the child support the intervention?

Is the benefit to self or others greater than the risk or harm?

All the relevant factors must be considered in assessing whether benefit to self or others is greater than the risk or harm. These include not only the medical benefits and harms, but also all other benefits and harms. The evidence for these benefits and harms must be carefully considered. If having considered all this, the question is answered in the negative then the intervention may not be performed. If the answer is positive or it is unclear whether it is negative or positive, then one should proceed to the second question.

Is the harm or risk excessive?

Even if the harms or risks of harm are outweighed by the benefits, they may nonetheless be excessive. That is to say, they may be greater than can reasonably be authorized under the circumstances by a second party on behalf on an incompetent being. What constitutes excessive harm or risk varies depending on whether the expected beneficiary is the child on whom the intervention is performed or others. It is reasonable to run greater risks and inflict greater harms if the beneficiary is the same child than if it is somebody else. What constitutes excessive harm or risk also varies depending on whether the answer to the first question is positive or is uncertain. The less certain the intended benefits, the less the risk or harm that can be sanctioned.

Of course, what constitutes ‘‘excessive’’ in either case is open to some interpretation, but only within a certain range. Some risks or harms will be clearly

excessive and others will clearly not be so. A positive answer to the second question renders the intervention impermissible. If the answer is negative and the child is an infant, then the intervention may be performed. If the answer is negative and the child is partially competent, one should proceed to the third question.

Does the child support the intervention?

There are two relevant variables to consider here. The first is the extent of the child’s competence. The more competent the child, the more weight should be put on his or her judgement about whether the intervention should be performed. The second variable is the reasonableness of the child’s preference. The smaller the margin whereby the benefits outweigh the harms and the closer the harms are to the excessive threshold the more weight should be attributed to a child’s preference not to have the intervention performed. The more the benefits outweigh the harms, and the further the harms are from the excessive threshold, the more weight should be given to a child’s preference to have the intervention performed. The two variables interact in the following way. The more competent the child the less reasonable his or her judgement need be to carry the same weight.

The case

Ordinarily, harvesting bone marrow from a young child in order to save the life of his or her sibling is a justifiable intervention. The risks of serious harm to the donor are negligible. To be sure, the process of harvesting the marrow is quite painful, but this cost is outweighed by the considerable benefit to the child’s sibling. The donor also benefits indirectly by not losing a sibling. In addition to the short-term loss of a sibling, there may be a considerable psychological burden later in life, if the would-have-been donor learns, once she grows up, that her deceased sibling could well have survived had she been used as a donor. The sister is too

young to understand the situation and thus her (absent) views cannot be taken into account.

There are two complicating factors in our case. Firstly, we need to know how much more suitable a donor the child is than her mother. If the difference is only minor, then the slightly decreased chances of success may be warranted by the preferability of using a consenting adult rather than a nonconsenting child as the donor. Second, although the mother is willing to authorize the harvesting of her daughter’s bone marrow, the father has reservations. His concerns need to be addressed. If he cannot make a good case for refusing to allow his daughter to be a donor, then he should be persuaded of the justification for permitting the harvesting of her bone marrow. The life of his son is not all that lies in the balance. Unless the mother and father can reach agreement, a deep rift between them is likely to develop, particularly if the daughter is not used as a donor and the son subsequently dies.

RECOMMENDED READING

Benatar, D. (ed.) (2006). Cutting to the Core: Exploring the Ethics of Contested Surgeries. Lanham MD: Rowman and Littlefield.

Benatar, M. and Benatar, D. (2003). Between prophylaxis and child abuse: the ethics of neonatal circumcision.

Am J Bioethics 3: 35–48.

Carr, C. (1978). Children, medical research and informed consent. J Soc Philos 9: 14–18.

Dawson, A. (2005). The determination of ‘‘best interests’’ in relation to childhood vaccinations. Bioethics 19: 188–205.

Fleck, L. M. (2004). Children and organ donation: some cautionary remarks. Camb Q Healthc Ethics 13: 161–6.

Jansen, L. A. (2004). Child organ donation, family autonomy, and intimate attachments. Camb Q Healthc Ethics 13: 133–42.

Ladd, R. E. (2004). The child as living donor: parental consent and child assent. Camb Q Healthc Ethics 13: 143–8.

Redmon, R. B. (1986). How children can be respected as ‘‘ends’’ yet still be used as subjects in non-therapeutic research. J Med Ethics 12: 77–82.

Sommerville, M. (2000). Altering baby boys’ bodies: the ethics of infant male circumcision. In The Ethical Canary: Science, Society, and the Human Spirit. Toronto: Viking, pp. 202–19.

Viens, A. M. (2004). Value judgment, harm and religious liberty. J Med Ethics 30: 241–7.

Zinner, S. (2004). Cognitive development and pediatric consent to organ donation. Camb Q Healthc Ethics 13: 125–32.

A six-year-old girl and her older sister are brought by their father to be evaluated for a history of cough, runny nose, and low-grade fever. In addition to signs of a cold, the physician notes that the girl’s nasal bridge is quite swollen and bruised. When asked what happened, she innocently shrugs her shoulders, and her father’s only conjecture is that since she sleepwalks she might have bumped into something. The father sits impatiently, but as questioning progresses becomes increasingly defensive, at one point angrily declaring ‘‘we don’t beat our kids, if that’s what you’re asking.’’ Further complicating the situation is information from several nurses that this family is ‘‘on the brink’’ both socially and financially, and that additional stress is likely ‘‘to blow this family apart.’’

What is child abuse and neglect?

The term child abuse encompasses physical abuse, sexual abuse, psychological abuse, and neglect – though the phrase ‘‘child abuse and neglect’’ is also common parlance. In its typical usage, child abuse refers to actions (or failures to act) by a parent or caregiver that result in serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm.

Why are ethical issues regarding child abuse and neglect important?

What could be more simple than the ethics of child abuse? For those who commit it, don’t. For everyone else, do what you can to protect children from

it. As one looks more deeply, though, definitions, interpretations, conflicting responsibilities, and, most prominently, uncertainty (on a range of issues) raise difficult questions. What exactly counts as abuse? How should we understand reasonable suspicion (which serves as the trigger for mandated reporting)? How sure must we be that abuse has occurred before initiating a child abuse investigation? Knowing that biases are inevitable in our assessments of risk and probability, how can we treat families fairly in our efforts to protect children from abuse? Finally, what should we as mandated reporters do when we do not think that reporting abuse is in a given child’s best interest?

In addressing these questions, there are several important things to understand about child abuse. Firstly, it is prevalent. In one Canadian study of over 10 000 households, 21% of women and 31% of men reported having been physically abused as children (MacMillan et al., 1997). In the USA in 2004 there were over 3.4 million investigations for suspected child abuse, with 872 088 confirmed cases, and at least 1490 deaths (Gaudiosi, 2006). Moreover, there is reason to believe that these numbers significantly underestimate the true incidence of abuse (Finkelhor, 1990; Herman-Giddens et al., 1999; Crume et al., 2002). Secondly, it is ubiquitous. One finds child abuse occurring in every community and at all levels of society (Finkelhor, 1994; Wyatt et al., 1999; Lampe, 2002; Lalor, 2004; Daro, 2006; Gaudiosi, 2006), though a variety of risk factors do make abuse more likely. Those at increased risk include children who are

younger, acutely ill, have chronic medical conditions and/or behavioral disorders, or have low intelligence (Warner and Hansen, 1994; Levitzky and Cooper, 2000; Gaudiosi, 2006). Family characteristics that predispose to abuse include increased stress, marital conflict, a young and/or single parent, unwanted pregnancy, and poverty (Warner and Hansen, 1994; Kotch et al., 1995; Brown et al., 1998; Drake and Zuravin, 1998; Overpeck et al., 1998). Thirdly, it has significant sequelae: bruises, lacerations, sexually transmitted diseases, pregnancy, post-traumatic stress disorder, chronic somatic disorders, serious brain injury, plus acute and chronic medical care (Irazuzta et al., 1997; Emery and Laumann-Billings, 1998; Widom, 1999; Discala et al., 2000; MacMillan et al., 2001; Diaz et al., 2002; Fein et al., 2002; Lansford et al., 2002; Scheid, 2003). Recent estimates for the USA alone put the total direct costs related to child abuse at more than $24 billion annually, with indirect costs exceeding $64 billion (Fromm, 2001).

There are significant interpersonal and cultural variations in terms of what counts as child abuse (Hansen, 1997; Dubowitz et al., 1998; FitzSimmons et al., 1998; Daro, 2006). An illustration of this is recounted by Dr. Catherine DeAngelis, editor of the

Journal of the American Medical Association, from her years teaching police officers about child abuse: ‘‘I started each new class by asking how many had ever spanked a child; almost all hands were raised. I then asked how many had ever beaten a child; no hand was ever raised. I then asked them to explain the difference, and the fun began’’ (Fargason et al., 1996).

At root, DeAngelis’ question is about harm and proportionality. In meting out punishment, how much harm is acceptable before the threshold into abuse has been crossed? Research tells us that our answers are heavily influenced by individual attitudes regarding discipline, as well as our personal experiences with corporal punishment (Howe et al., 1988; Hansen, 1997; Bonardi, 2000; Jankowski and Martin, 2003; Tirosh et al., 2003). So, too, significant cultural norms come into play (Daro, 2006). Some communities hold that beating children is a

sign of love and commitment (Visser and Miller, 2002; Rakundo, 2006) whereas others (e.g., almost half of European countries) have outlawed even routine spanking (Daro, 2006). At times, it will be difficult to identify precise cutoffs, and inevitably reasonable people will disagree whether a given practice qualifies as legitimate discipline or abuse. But no reasonable person would dispute the notion that an adult who non-accidentally inflicts serious harm on a child commits an act of abuse (Chen, 2004; Maiter and Alaggia, 2004; Daro, 2006).

Though less central than harm, intention also figures into what we consider abuse. A parent can bruise their child by accident, or out of anger, or by pulling them out of harm’s way, or even by administering non-traditional medical therapy. In each case, the parent’s intention influences not only the nature of our response but also our judgement whether their action qualifies as abuse. Again, there are cultural components to this. Certain practices (e.g., coining, circumcision, scarification, and other body manipulations) are accepted because, within their cultural context, they are not intended to harm. But good intentions do not render any practice immune from being judged abuse. Children have the right to an open future (Feinberg, 1980) as well as the right to protection from serious harm (Archard, 2002). ‘‘Well-intended’’ culturally bound practices that violate these rights, and in so doing cause significant harm, do constitute abuse. Examples include severe shaking of an infant to raise a sunken fontanelle (i.e., caida de Mollera) or cutting off a girl’s clitoris and labia, then sewing her vagina shut (i.e., clitoridectomy and infibulation). The intention of these acts may mitigate our reactions to the adults who carry them out. But the lasting injuries and impairment and psychological damage that befall children who are subjected to such acts are testament to the abusive nature of these practices (Barstow, 1999; Chalmers and Hashi, 2000; el-Defrawi et al., 2001; Refaat et al., 2001; Whitehorn et al., 2002; Nour, 2003; K. M. Yount and D. L. Balk, unpublished data). The growing criticism from within cultures that engage in these practices simply reinforces the judgement