Parents sometimes deny their children the benefits of medical care because of religious beliefs. In some jurisdictions, exemptions to child abuse and neglect laws restrict government action to protect children or seek legal redress when the alleged abuse or neglect has occurred in the name of religion. The American Academy of Pediatrics (AAP) believes that all children deserve effective medical treatment that is likely to prevent substantial harm or suffering or death. In addition, the AAP advocates that all legal interventions apply equally whenever children are endangered or harmed, without exemptions based on parental religious beliefs. To these ends, the AAP calls for the repeal of religious exemption laws and supports additional efforts to educate the public about the medical needs of children.
- AAP =
- American Academy of Pediatrics
The American Academy of Pediatrics (AAP) recognizes that religion plays a major role in the lives of many children and adults in the United States and is aware that some in the United States believe prayer and other spiritual practices can substitute for medical treatment of ill or injured children. Through legislative activity at the federal and state levels, some religious groups have sought, and in many cases attained, government recognition in the form of approved payment for this “nonmedical therapy” and exemption from child abuse and neglect laws when children do not receive needed medical care. The AAP opposes such payments and exemptions as harmful to children and advocates that children, regardless of parental religious beliefs, deserve effective medical treatment when such treatment is likely to prevent substantial harm or suffering or death.
The US Constitution requires that government not interfere with religious practices or endorse particular religions. However, these constitutional principles do not stand alone and may, at times, conflict with the independent government interest in protecting children.1 Government obligation arises from that interest when parental religious practices subject minor children to possible loss of life or to substantial risk of harm.2,3Constitutional guarantees of freedom of religion do not permit children to be harmed through religious practices, nor do they allow religion to be a valid legal defense when an individual harms or neglects a child.4
Acute Illness or Injury
The AAP asserts that every child should have the opportunity to grow and develop free from preventable illness or injury.5Children also have the right to appropriate medical evaluation when it is likely that a serious illness, injury, or other medical condition endangers their lives or threatens substantial harm or suffering. Under such circumstances, parents and other guardians have a responsibility to seek medical treatment, regardless of their religious beliefs and preferences. Unfortunately, certain groups have obtained exemptions from legal sanctions and state child abuse and neglect reporting laws based on the child's “treatment” by spiritual means, such as prayer.6 The overall effect has been to limit the government's ability to protect children from abuse or neglect.
The AAP is concerned about religious doctrines that urge parents to avoid seeking medical help when their children are seriously ill. Each year, some parents' religious views lead them to eschew appropriate medical care for their children, resulting in substantial harm or suffering or death due to treatable conditions such as meningitis, bowel obstruction, diabetes mellitus, or pneumonia (Boston Globe. August 12, 1993:1; Pittsburgh Post-Gazette.March 16, 1991:B1).4,7 The AAP considers failure to seek medical care in such cases to be child neglect, regardless of the motivation. The basic moral principle of justice requires that children be protected uniformly by laws and regulations at the local, state, and federal levels. Parents and others who deny a child necessary medical care on religious grounds should not be exempt from civil or criminal action that otherwise would be appropriate. State legislatures and regulatory agencies should remove religious exemption clauses from statutes and regulations to ensure that all parents understand that they should seek appropriate medical care for their children.
Some religious tenets hold that members should not seek or receive medical care for any condition, including pregnancy. These beliefs can result in increased perinatal and maternal mortality.8 Some religious groups deny children the benefits of routine preventive care. For example, some parents, acting in accord with state laws, refuse to have their children immunized because of religious beliefs. The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations. Although the risk to unimmunized individuals is relatively low, serious adverse reactions to vaccination are rare and the AAP strongly endorses universal immunization. Recent outbreaks of vaccine-preventable infectious diseases, with consequent serious complications and deaths, have been linked to groups that refused immunization for religious reasons.9-12
The AAP therefore supports the use of appropriate public health measures, such as mandatory mass vaccinations in epidemic situations, when necessary to protect communities and their unimmunized members. In addition, the AAP is concerned that children unimmunized for any reason may expose young children, not yet old enough to be protected, to infections such as pertussis or invasive Haemophilus influenzae disease. The risk is especially high in child care facilities. In such situations, all parents of children in the facility should be informed of the hazards.
The weight given to parental religious beliefs in decisions affecting their children's well-being declines with the child's increasing age and development. That is, as minors mature, their interest in and capacity for participating in health care decisions affecting themselves increases, as does their ability to make decisions regarding their parents' religious views. The law and AAP policy recognize the doctrine of the “mature minor.”13 This concept acknowledges that many children, usually beginning in adolescence, can contribute to or make medical decisions, including those about life-sustaining treatment. Thus, in selected cases, disputes may be avoided when a minor has the capacity to make an independent decision in light of religious values and recommended medical therapy.
Need for Care and Respect
The AAP wishes to underscore its recognition of the important role of religion in the personal, spiritual, and social lives of many individuals and cautions physicians and other health care professionals to avoid unnecessary polarization when conflict over religious practices arises. Pediatricians should seek to make collaborative decisions with families whenever possible and should take great care when considering seeking authority to override parental preferences. Nevertheless, physicians who believe that parental religious convictions interfere with appropriate medical care that is likely to prevent substantial harm or suffering or death should request court authorization to override parental authority or, under circumstances involving an imminent threat to a child's life, intervene over parental objections. When caring for children whose prognoses are grave even with treatment, physicians should use restraint in pursuing a court order to initiate or continue treatment when parents object to it. In such situations, physicians should work with the parents and children to ensure provision of appropriate palliative care. Threatening or seeking state intervention should be the last resort, undertaken only when treatment is likely to prevent substantial harm or suffering or death. Even under these circumstances, physicians should respect parental religious beliefs and the role of parents in rearing their children. Of course, a physician may withdraw from these cases, after securing acceptable alternative medical care, when continuing in the doctor-patient-family relationship would violate the physician's own moral precepts.
The AAP emphasizes that all children who need medical care that is likely to prevent substantial harm or suffering or death should receive that treatment. The AAP opposes religious doctrines that advocate opposition to medical attention for sick children. Adherence to such views precludes appropriate assessment and intervention to protect the children. The AAP believes that laws should not encourage or tolerate parental action that prevents implementing appropriate medical treatment, nor should laws exempt parents from criminal or civil liability in the name of religion.
The AAP calls for all those entrusted with the care of children to:
show sensitivity to and flexibility toward the religious beliefs and practices of families;
support legislation that ensures that all parents who deny their children medical care likely to prevent death or substantial harm or suffering are held legally accountable;
support the repeal of religious exemption laws; and
work with other child advocacy organizations and agencies and religious institutions to develop coordinated and concerted public and professional action to educate state officials, health care professionals, and the public about parents' legal obligations to obtain necessary medical care for their children.
Committee on Bioethics, 1995 to 1996
Joel E. Frader, MD, Chairperson
Lucy S. Crain, MD
Kathryn L. Moseley, MD
Robert M. Nelson, MD
Ian H. Porter, MD
Felipe E. Vizcarrondo, MD
Watson Bowes, MD
American College of Obstetricians & Gynecologists
Alessandra Kazura, MD
American Academy of Child & Adolescent Psychiatry
Ernest F. Krug III, MD
American Board of Pediatrics
Donna A. Caniano, MD
Section on Surgery
Nancy M. P. King, JD
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
- ↵Planned Parenthood of Central Missouri v Danforth, 428 US 52, 74(1976)
- ↵Prince v Commonwealth of Massachusetts, 321 US 158, 170(1944)
- ↵Jehovah's Witnesses v King County Hospital Unit No. 1, 278 F Supp 488 (WD Wash 1967), affirmed per curiam 390 US 598(1968)
- ↵Walker v Superior Court, 763 P2d 852, 860 (Calif 1988), cert denied, 491 US 905(1989)
- ↵UN Convention on the Rights of the Child. New York, NY: United Nations; 1989
- ↵Skolnick A. Religious exemptions to child neglect laws still being passed despite convictions of parents. JAMA. 1990;264:1226, 1229, 1233
- ↵State of Minnesota v McKown, 475 NW2d 63 (Minn 1991), cert denied, 112 S Ct 882(1992)
- Etkind P,
- Lett SM,
- Macdonald PD,
- Silva E,
- Peppe J
- Committee on Bioethics, American Academy of Pediatrics
- Copyright © 1997 American Academy of Pediatrics