The authors examined children's and adolescents' desire to be involved in serious medical decisions and the emotional consequences associated with them. Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: 1 own informed choice; 2 informed parents' choice to amputate; 3 informed parents' choice to continue a treatment; and 4 uninformed parents' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice.
Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants' responses.
Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel.
The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process. As part of an attempt to increase children's participation in decision making, Articles 12 and 13 of the United Nations Convention on the Rights of the Child specify that minors have the right to express themselves freely, be heard on all matters affecting them, and have their views taken seriously .
In recent years, there has been a shift from a paternalistic medical model, where physicians and parents hold an authoritative role in determining a child's treatment, to one advocating minors' involvement in their medical treatment .
A Difficult Decision - Term Paper
Simultaneously, the US Supreme Court has come to recognize that minors who show maturity and competence deserve a voice in determining their medical treatment and even allows minors, in cases such as abortion, treatments for substance abuse and sexually transmitted diseases, and contraception, to receive treatment without parental consent or notification .
Do children and adolescents welcome this change, wishing to be actively involved and taking responsibility for medical decisions regardless of the severity of the decision? Can they anticipate their emotional reactions to these choices? Research on shared medical decision making among minors has so far focused on legal and ethical issues e. Although these are important issues, researchers have neglected to examine minors' views and feelings about this decision-making process.
What did Botti et al. Imagine facing the following scenario: A premature baby's life is sustained by a ventilator, and after 3 weeks of treatment the baby's condition has not improved. Moreover, envision that you can make the decision yourself or have the physician assume responsibility for the decision . Thus, according to Botti et al. In three studies, Botti et al. They showed that adults for whom the doctor made the decision reported significantly fewer negative emotions than adults who made the choice themselves.
They proposed that ascribing personal causation to an event intensifies negative emotions associated with a difficult choice.
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Two additional findings from Botti et al. First, not informing participants about treatment options and their outcomes eliminated the emotional advantages associated with transferring the choice to another agent. Second, despite feeling worse after the decision, choosers were reluctant to give up their autonomy. Whether children and adolescents behave and react similarly when making difficult choices is an open and important question. If medical professionals are to include minors in the medical decision-making process, there may be times when they have to present minors with difficult choices e.
In this study, we first manipulated who made the decision: the minor or the minor's parents; second, we manipulated which option was chosen by parents; and, finally, we manipulated whether information was given about all the possible treatment options. This allowed us to examine which of these factors agent making the choice, choice taken, information provided affect children's and adolescents' decision confidence and emotional reactions in difficult choice situations and, ultimately, whether minors prefer to make a difficult choice themselves, despite being able to anticipate the negative emotional consequences associated with this choice.
Given the paucity of data on the topic, our investigation could have clinical implications for physicians and possibly parents who must decide whether to include minors in the medical decision-making process. There is good evidence that adolescents in particular are increasingly interested in making decisions independent of adults  , . Compared to children, adolescents regard more issues as a matter of personal choice, have a stronger desire to be independent, and are more likely to question authority figures' decisions . Hence, we expected that when faced with difficult medical decisions, adolescents compared to children would show a stronger preference for making autonomous decisions Hypothesis 1.
According to Botti et al. Thus, despite children's and adolescents' willingness to make a decision autonomously, we would expect participants to experience a less negative emotional response when the difficult choice was made by their parents Hypothesis 2. Indeed, even though adolescents want to be autonomous decision-makers, they are still seeking advice from a person they consider more competent and knowledgeable than themselves . This is particularly true when decisions involve physical harm or moral and social-conventional transgressions . Adolescents acknowledge that authority-based decision procedures can be more suitable in some environments where adults might have more competence and better knowledge e.
Similarly, the confidence that the best decision was made might depend on either the agent minor or parent making the decision or the decision option chosen.
We therefore explored two alternative—but not mutually exclusive—hypotheses: a If the agent making the decision is the most important element, we expected that participants, and especially adolescents, would show higher decision confidence when they made the decision themselves than when the parents made the decision, independent of the decision option chosen by the parents; b if the decision option chosen influences decision confidence, participants should be equally confident that the right decision was made when one particular option was chosen, independent of who they themselves or the parents made the decision Hypotheses 3a and 3b respectively.
We also investigated which decision children and adolescents take, and explored whether and how the decision taken affected desire for autonomy, emotional response and decision confidence. Finally, we hypothesized that minors would be sensitive to the information provided to make a decision Hypothesis 4. That is, the negative emotional response and the confidence that the best decision was made would be worse if no information about the treatment options and outcomes were provided see .
Participants were all white, and none of them suffered a chronic medical or psychiatric condition that could have constrained or influenced a correct and neutral understanding of the instructions. The experimental procedures were approved by the ethics committee of the Max Planck Institute for Human Development, and all the parents of the children involved, as well as the teachers and the schools' Institutional Review Board, were informed and consented in written form to let the children participate prior to data collection.
Participants were asked to give their assent to participate, and were free to leave the classroom and withdraw from the experiment at any time. All participants received a piece of paper with an introduction to a scenario, common to all conditions, and a description of the specific condition to which they were assigned see below.
All participants of one age group assigned to the same condition were tested together. The experimenter read the scenario aloud. Participants were asked to imagine they had had an accident 1 week before: They had been hit by a car while walking home from school. As a result of the accident, they had a broken leg and were suffering from a severe infection.
After the first 10 days of treatment they did not get any better. Participants were randomly assigned to one of four conditions: 1 own informed choice; 2 informed parents' choice to amputate; 3 informed parents' choice to continue the treatment; and 4 uninformed parents' choice to amputate. The number of participants in each condition for each age group is presented in Table 1.
In the informed Conditions 1, 2, and 3, the doctor presented to the participants and their parents two alternatives: Continue the treatment or amputate the leg. If they continued with the treatment, there were 4 chances out of 10 that the infection would dangerously spread, and 6 chances out of 10 that the doctors would save the leg.
Even if the doctors saved the leg, it would be seriously damaged and would hurt a lot, and the participant would not be able to run again. These survival odds were the same as in the Botti et al. In Condition 1 own informed choice , participants were asked to decide whether to amputate their leg. In Condition 2 informed parents' choice , participants' parents made the decision to amputate the leg.
In Condition 3 informed parents' opposite choice , participants' parents made the decision not to amputate but to continue the treatment.
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In Condition 4 uninformed parents' choice , the doctor did not mention the option to continue the treatment nor the outcome probabilities associated with the two alternatives, and the decision to amputate the leg was made by the parents. After hearing the scenario, each group completed a questionnaire, almost identical to the one administrated by Botti et al. Only participants in Condition 1 own informed choice were asked for their decision on whether to amputate the leg and their reasons for their choice.
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Participants in all conditions were asked to indicate to what extent each of five negative emotions nervous, upset, unhappy, concerned, guilty described how they felt about the treatment decision on a scale from 1, not at all , to 9, extremely. Next, participants had to indicate how confident they were that the best decision had been made on a scale from 1, not at all , to 9, extremely.
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The final two questions measured participants' preference for decision autonomy. Participants in Condition 1 own informed choice were asked how much they liked having to make the decision and how much they would have preferred that their parents made the decision for them. Participants in Conditions 2, 3, and 4 informed parents' choice, informed parents' opposite choice, uninformed parents' choice were asked how much they liked not having to make the decision and how much they would rather have made the choice themselves.
The response scale for both questions ranged from 1 not at all to 9 extremely. A difficult conversation is any conversation that you dread and perhaps seek to avoid, if possible. There are the situations that keep you up at night in anticipation that you put off or face up to like bad medicine. Our typical approach to the complexity of what happened, the reality of feeling and potential threat to our identity tend to make our conversations more difficult, rather than more productive, often escalating conflict, hurting feelings and damaging relationships indeed, it is our intuitive understanding of this danger that leads us to want to avoid such conversations given how we are likely to handle the conversations, our fears are justified.
But unfortunately sometimes assumptions make avoiding a conversation just as problematic. We continue to feel upset. We may feel like such a wimp for not standing up for ourselves.