This editorial appears in the November 2025 Issue of the American Journal of Bioethics
Navigating conflict over medical decisions for children is a central theme in pediatric bioethics, an ever-present challenge for clinicians at the bedside and the topic of considerable scholarly work by bioethicists. Much of the debate focuses on what parents decide for their children and whether those choices fall within an ethically permissible range. Far less attention has been paid to why parents decide what they do and whether those reasons ought to matter. In their thoughtful article, “Do Reasons Matter? Navigating Parents’ Reasons in Healthcare Decisions for Children,” Moore and Caruso Brown challenge the dominant view that parents’ reasons are ethically irrelevant. They argue that reasons are not only clinically meaningful but ethically significant, and they invite us to rethink how we evaluate parental authority, and our own biases, in pediatrics.
Traditionally, whether a parent declines medical therapy out of religious conviction or out of fear of financial ruin, the action is judged by the same yardstick: Does it meet a minimum threshold of beneficence (as demanded by the best interest standard), or does it place the child at significant risk of serious harm (as asked by the Harm Principle or the Zone of Parental Discretion)? Though understanding the “why” behind a parent’s decision may be crucial for communication, negotiation, and trust-building, the dominant position in Western bioethics posits that only the choice matters, not the underlying rationale. Moore and Caruso Brown reconsider this stance.
Moore and Caruso Brown’s central claim is that reasons matter in at least three ways. First, reasons matter pragmatically. Reasons may illuminate opportunities for alignment, compromise, or correction. Second, reasons and motivations may shift our understanding of the value-laden estimations of “benefit” or “burden” and may shape ethical deliberation of what is ethically permissible. Understanding motivations may help clinicians and bioethicists understand better whether a choice truly aims at the child’s best interests. Third, reasons highlight social and cognitive biases (held by both clinicians and parents) that may sway decision-making. Moore and Caruso Brown ask clinicians and bioethicists to move beyond a binary moral landscape of ethically permissible/impermissible decisions and to consider the nuance and weight that reasons bring to the decision-making calculus.
Unsurprisingly, their article spurred an impressive 17 open peer commentaries from experts across the field of pediatric bioethics, ranging from solid endorsement to outright disagreement, from concerns about exacerbating injustice to requests for application in real-world clinical contexts. The resulting collection of articles serves to deepen and enrich the literature concerning the balance of decisional authority in pediatrics.
While the authors of these commentaries largely agree that parental reasons are of pragmatic importance, they differ regarding whether and how reasons matter ethically, and how clinicians and bioethicists ought to respond. Perhaps most controversially, Moore and Caruso Brown argue that parental reasons may “make a heretofore unethical decision ethical, or, conversely, make what we thought was an ethically permissible decision impermissible … by shifting the boundaries or changing the scope of intervention principles”. Several commentaries critically examine this position, arguing that allowing parental reasons to determine ethical permissibility risks centering decision-making on something other than the child’s best interests and fundamentally alters the guardrails of intervention principles. Other raise concern that giving reasons moral weight subjugates decision-making to personal subjectivity and bias and may worsen the very procedural and distributive injustice that Moore and Caruso Brown seek to address.
Some commentaries urge Caruso Brown and Moore to delve more deeply into why reasons matter normatively, going so far as to suggest that it is not parental reasons per se but parental core commitments or the conception of what it means to be a good parent that matters ethically. Using a different test case—prescribing GLP-1 agonists for an overweight child—Acors and Peugh emphasize the role of reasons to provide insight into parents’ values, while cautioning against clinicians judging those values and “deciding which to respect and which to dismiss.”
Taking parental reasons seriously introduces new challenges for clinicians and healthcare ethics consultants. Several commentaries suggest that healthcare ethics consultation must adopt different practice models to ensure that parental (and child) reasons and narratives carry sufficient weight in deliberation. As Moore and Caruso Brown acknowledge, judgments about motivation are susceptible to bias and inconsistency, which may permit reasons to exacerbate inequity and injustice. Irfan, Kazi, and Sirvent, Yang et al., and Gopalan remind us that religious and cultural norms, respectively, shape what count as “good” reasons. They caution about the risk of epistemic injustice that may stem from questioning parental reasons arising from outside the realm of Western secularism, individualism, and rationalism and call for a commitment to pluralism and cultural and epistemic humility. Yang et al. also demonstrate the dangers of relying on parental reasons when parents—and their reasons—may be subject to emotional manipulation and cognitive distortion in the face of caring for their sick child. Going further, Cavolo argues that parental reasons matter, in part, because of the socioeconomic conditions that make it impossible for parents to focus solely on their child’s best interests; addressing structural barriers to ethical decision-making requires that clinicians and bioethicists work proactively and systemically to develop innovative dispute resolution models and improve the conditions surrounding decision-making and the choices available to parents, rather than relying on state intervention.
Superseding parental authority by requesting state intervention is the most coercive step a clinical ethicist can recommend. Yet in our experience as healthcare ethics consultants, bedside clinicians sometimes invoke or threaten state intervention at a much lower threshold than established intervention principles require. When clinicians ask, “Should we call Child Protective Services?” we often find that clinicians do not know or understand the reasons for the parents’ decisions, feel powerless to secure what they believe will best serve their patient, and believe that calling Child Protective Services is the only tangible tool available to resolve intractable conflict. In many of these cases the parental choices at issue are ethically permissible, even if they are not the choices the clinicians themselves would make.
In these cases, exploring parental reasons and acknowledging their ethical relevance does not move the goalposts for intervention. Instead, we see that process as a necessary step in untangling conflict, supporting communication and connection between families and clinicians, and facilitating high-quality shared decision-making. This is the vital work of relational ethics: Through deliberate mediation, epistemic humility, and careful attention to bias, healthcare ethics consultants can create a more balanced space for all narratives to be heard, for understanding to emerge, and for innovative solutions to be identified.
Moore and Caruso Brown’s article reminds us that the moral lives of families—and the clinical relationships that support them—are saturated with reasons. To treat those reasons as irrelevant is to miss the moral weight of parental care and the nuance and complexity of pediatric decision-making. On that, the authors of the target article and the many accompanying Open Peer Commentaries agree. While the degree to which those reasons ought to alter the ethical permissibility of certain decisions remains unsettled, the discourse that our colleagues across the field of pediatric bioethics have provided here helps bridge the gap between ethical theory and clinical practice—and equips us to navigate pediatric care with both rigor and compassion.