The Relational Potential Standard: Rethinking the Ethical Justification for Life‐Sustaining Treatment for Children with Profound Cognitive Disabilities

Abstract

In this era of rapidly advancing biomedical technologies, it is not unusual for parents of children with profound cognitive disabilities to ask clinicians to provide invasive life‐sustaining treatments. Parental requests for such interventions pose a moral dilemma to the treating medical team, as there may be a discrepancy between the team's perception of the child's best interest and the apparent rationale underlying a parent's request. This gap highlights the limitation of the best interest standard in cases where, due to a neurodevelopmental disorder or brain injury, the child's capabilities are severely limited and their interests may be difficult to discern. The harm principle is also inadequate for decision‐making in response to these parental requests. To address these limitations, and inspired in part by John Arras's work on the relational potential standard, we propose an integration of care ethics within pediatric decision‐making using a new version of this standard. The potential for children to be in caring and loving relationships with their parents, what we will call “relational potential,” may provide an ethical justification for clinicians to support parental requests for life‐sustaining treatments.

Relationships help make life worth living

“…We view this finding as evidence of the respondents’ more general recognition of the moral value of caring relationships, particularly that between child and parent, and this may serve as a justification to support parental requests for interventions that go beyond comfort care. The public may hold a more inclusive interpretation of valued human relationships, even including those characterised by ‘minimal cognition’ or a lack of awareness, which may be more consistent with a recently proposed expansion and revision of the relational potential standard 6…”

“…In this study, the authors described relational capacity as only possible in a single vignette. This narrow interpretation of relational capacity may not match the threshold proposed by Arras, but more importantly, may not reflect the public’s or parents’ interpretation of a meaningful human relationship 4 6. While recognition of a broader relational potential may be supported by the observed deference to parents, it would have been interesting to see if the results would have been different had the authors offered a more inclusive interpretation of relational capacity.…”

“…Instead of focusing on a certain threshold of capability of an individual, the relational potential standard honours the capacity for a caring relationship to flourish, even if it appears largely one-sided to an outside observer 6. The value of relationships cannot be accounted for by individualistic frameworks such as a best interest standard because the health and well-being of the individual in the context of relationship with others also matters.…”

“…The value of relationships cannot be accounted for by individualistic frameworks such as a best interest standard because the health and well-being of the individual in the context of relationship with others also matters. Ultimately, once weighed against other considerations, including burden placed on the child and available societal resources, recognition of relational potential may support clinicians in actualising parents’ request for medical interventions that go beyond comfort care 6…”

The relational threshold: a life that is valued, or a life of value?

“…Wightman et al in their commentary4 cite a recently published account of an “expanded relational potential standard”. This expanded account, drawing on care ethics, recognises that parents may establish caring relationships even if that relationship is largely or entirely one-sided, and the “the child has limited or no capacity to reciprocate” 7…”