BALANCING LIBERATION AND PROTECTION: A MODERATE APPROACH TO ADOLESCENT HEALTH CARE DECISION‐MAKING

In this paper I examine the debate between ‘protectionists’ and ‘liberationists’ concerning the appropriate role of minors in decision‐making about their health care, focusing particularly on disagreements between the two sides regarding adolescents. Protectionists advocate a more traditional, paternalistic approach in which minors have relatively little input into the healthcare decision‐making process, and decisions are made for them by parents or other adults, guided by a commitment to the patient's best interests. Liberationists, on the other hand, argue in favour of expanded participation by minors in treatment decisions, and decision‐making authority for at least some adolescents. My examination of the debate includes discussion of liberationist shifts that have taken place in the medical community as well as in legal policy and practice, and consideration of recent research on adolescent development. In the final section of the paper, I propose a moderate position that addresses both liberationist and protectionist concerns.     

Parental refusal of life-saving treatments for adolescents: Chinese familism in medical decision-making re-visited

This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the 'AP-physician-family-relationship' and the dominant role Chinese families play in medical decision-making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives 'weak' family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re-interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its 'parens patriae' power to defend the defenseless in society and the integrity of the medical profession.     

Do Parents Meet Adolescents’ Monitoring Standards? Examination of the Impact on Teen Risk Disclosure and Behaviors if They Don’t

In this study, we examined how adolescents compare monitoring efforts by their parents to those of a "good parent" standard and assessed the impact of these comparisons on adolescent self-disclosure and risk behavior and their perceptions of their parents'' monitoring knowledge. Survey responses from 519 adolescents (12–17 years) at baseline of a larger, longitudinal study examining parental monitoring and adolescent risk were examined. Adolescents’ “good parent comparisons” differed greatly by monitoring areas (e.g., telephone use, health, money); however, between 5.5% and 25.8% of adolescents believed their parents needed to monitor their activities more than they currently were monitoring. Alternatively, between 8.5% and 23.8% of adolescents believed their parents needed to monitor their activities less often. These perceptions significantly distinguished adolescents in terms of their level of disclosure, perceived monitoring knowledge, and risk involvement. Adolescents who viewed their parents as needing to monitor more were less likely to disclose information to their parents (p<.001), less likely to perceive their parents as having greater monitoring knowledge (p<.001), and more likely to be involved in a risk behaviors (p<.001) than adolescents who perceived their parents needed no change. Adolescent disclosure to a parent is a powerful predictor of adolescent risk and poor health outcomes. These findings demonstrate that adolescents'' comparisons of their parents'' monitoring efforts can predict differences in adolescent disclosure and future risk. Obtaining adolescent "good parent" comparisons may successfully identify intervention opportunities with the adolescent and parent by noting the areas of need and direction of monitoring improvement.     

Supportive family relationships and adolescent health in the socio-cultural context of Iran: a qualitative study

Parents have a critical role in adolescent health. The association of adolescents'' perceptions of family relationships with adolescent health was investigated using a sample of 67 female adolescents who participated in eight focus group discussions, utilising a purposeful sampling method. All tape-recorded data were fully transcribed and content analysis was performed. Three themes were identified, namely emotional support, responsible parents and well-informed parents. With regard to some of the challenges in Iranian adolescents'' relationships with their parents, it is necessary to educate parents to be alert to their role in adolescent health.     

The Relationship between Parental Depressive Symptoms,Family Type,and Adolescent Functioning

It is evident that parental depressive symptoms negatively influence adolescent behavior and various psychosocial outcomes. Certain family types like families with a chronically ill parent and single parent families are more vulnerable to parental depressive symptoms. However, the relationship between these symptoms, family type, and adolescent functioning remains largely unclear. This study examined relations between self-report of parental depressive symptoms and adolescent functioning in 86 two-parent families including a parent with a chronic medical condition, 94 families with healthy single parents, and 69 families with 2 healthy parents (comparison group). Parents completed the Beck Depression Inventory. Adolescents filled in the Youth Self-Report measuring problem behavior, and other instruments measuring psychosocial outcomes (stress, grade point average, school problems, and self-esteem). Multilevel analyses were used to examine the effects of family type, parental depressive symptoms, adolescents'' gender and age, and interaction effects on adolescent functioning. The results indicated that adolescents with chronically ill and single parents had a lower grade point average (p<.01) than the comparison group. Adolescents of single parents reported more internalizing problems (p<.01) and externalizing problems (p<.05) than children from the other family types. Parental depressive symptoms were strongly related to child report of stress (p<.001). Adolescents of depressed chronically ill parents were particularly vulnerable to internalizing problems (interaction effect, p<.05). Older children and girls, and especially older girls, displayed more internalizing problems and stress. It can be concluded that growing up with a chronically ill parent in a family with 2 parents may have less impact on adolescent problem behavior than growing up in a single parent family. Health practitioners are encouraged to be attentive to the unique and combined influence of family type and parental depressive symptoms on adolescent functioning. Older and female adolescents deserve particular attention.     

Family Socialization Practices and Their Effects on the Internalization of Educational Values for Asian and White American Adolescents

Based on the theories of internalization and the self, this article examines effective family socialization practices of Asian and White Americans. The results indicated that parental support for autonomy and adolescents' perceived competence while studying favorably affected Asian Americans' internalization of their cultural values relevant to education and academic success. In contrast, for White Americans, these internalization factors did not have a substantial effect on adolescents' school performance. Moreover, for Asian Americans, parents' attitudes had stronger effects on adolescents' school performance in comparison to White American adolescents, whose teacher-awarded grades were attributed to their own academic aspirations. Differences in family socialization practices between Asian and White Americans are discussed within a context of underlying cultural frameworks that promote adolescents' school performance.     

POSTNATAL REPRODUCTIVE AUTONOMY: PROMOTING RELATIONAL AUTONOMY AND SELF-TRUST IN NEW PARENTS

New parents suddenly come face to face with myriad issues that demand careful attention but appear in a context unlikely to provide opportunities for extended or clear-headed critical reflection, whether at home with a new baby or in the neonatal intensive care unit. As such, their capacity for autonomy may be compromised. Attending to new parental autonomy as an extension of reproductive autonomy, and as a complicated phenomenon in its own right rather than simply as a matter to be balanced against other autonomy rights, can help us to see how new parents might be aided in their quest for competency and good decision making. In this paper I show how a relational view of autonomy – attentive to the coercive effects of oppressive social norms and to the importance of developing autonomy competency, especially as related to self-trust – can improve our understanding of the situation of new parents and signal ways to cultivate and to better respect their autonomy.     

Research Integrity in Greater China: Surveying Regulations,Perceptions and Knowledge of Research Integrity from a Hong Kong Perspective

In their 2010 article ‘Research Integrity in China: Problems and Prospects’, Zeng and Resnik challenge others to engage in empirical research on research integrity in China. Here we respond to that call in three ways: first, we provide updates to their analysis of regulations and allegations of scientific misconduct; second, we report on two surveys conducted in Hong Kong that provide empirical backing to describe ways in which problems and prospects that Zeng and Resnik identify are being explored; and third, we continue the discussion started by Zeng and Resnik, pointing to ways in which China's high‐profile participation in international academic research presents concerns about research integrity. According to our research, based upon searches of both English and Chinese language literature and policies, and two surveys conducted in Hong Kong, academic faculty and research post‐graduate students in Hong Kong are aware of and have a positive attitude towards responsible conduct of research. Although Hong Kong is but one small part of China, we present this research as a response to concerns Zeng and Resnik introduce and as a call for a continued conversation.     

Parental recognition of overweight in school-age children

Objective: Examine the accuracy of parental weight perceptions of overweight children before and after the implementation of childhood obesity legislation that included BMI screening and feedback. Methods and Procedures: Statewide telephone surveys of parents of overweight (BMI ≥ 85th percentile) Arkansas public school children before (n = 1,551; 15% African American) and after (n = 2,508; 15% African American) policy implementation were examined for correspondence between parental perception of child's weight and objective classification. Results: Most (60%) parents of overweight children underestimated weight at baseline. Parents of younger children were significantly more likely to underestimate (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate, nor was inaccuracy associated with parental education or socioeconomic status. African‐American parents were twice as likely to underestimate as whites. One year after BMI screening and feedback was implemented, the accuracy of classification of overweight children improved (53% underestimation). African‐American parents had significantly greater improvements than white parents (P < 0.0001). Discussion: Parental recognition of childhood overweight may be improved with BMI screening and feedback, and African‐American parents may specifically benefit. Nonetheless, underestimation of overweight is common and may have implications for public health interventions.     

Presuming patient autonomy in the face of therapeutic misconception

Therapeutic misconception involves the failure of subjects either to understand or to incorporate into their own expectations the distinctions in nature and purpose of personally responsive therapeutic care, and the generic relationship between subject and investigator which is constrained by research protocols. Researchers cannot disregard this phenomenon if they are to ensure that subjects engage in research on the basis of genuine informed consent. However, our presumption of patient autonomy must be sustained unless we have compelling evidence of serious misunderstanding. This article argues that the mere expression of aspects of therapeutic misconception should not necessarily displace the presumption of subject autonomy or undermine ethical inclusion in research for at least three reasons. First, some interpretations of the empirical data do not suggest misunderstanding. Second, assessment of misestimation and optimism are delicate and value‐laden, and turn quickly from questions of autonomy to questions of judgment. Third, incomplete understanding may yet be sufficient to allow a subject to engage in a substantially autonomous decision‐making process. Our point is not to dismiss the possibility of genuine therapeutic misconception, but to question its frequency and fatality to the consent process.     

Explaining Chinese identification in Hong Kong: the role of beliefs about group malleability

ABSTRACT

Hong Kong is an epicentre of identity conflicts in China. While numerous accounts have been proposed to explain the rise of “localism”, few have explained why many Hong Kong Chinese have maintained their ethnic identification with China. Based on an original survey of a representative sample of the population and an experiment conducted among college students, this article advances a novel explanation, arguing that people who perceive the core character of groups as shaped by context (i.e. it is malleable) are more likely to have a higher level of Chinese identification. The explanation is that in the face of deep cultural and political differences between mainland and Hong Kong Chinese, the belief induces the latter to understand those differences as stemming from people’s current situations rather than from some unchangeable national traits, thus reducing their need to adopt an alternative identity. The findings have important implications on (ethno) nation-building policies.     

Sibling and environmental correlates of adolescents’ perceptions of family environments: Ethnic group differences

Abstract

Hierarchical regression analyses and response surfaces were used in an investigation of relationships between sibling variables and adolescents’ perceptions of their family environments, after the impact on the perceptions of earlier family measures was taken into account. The analyses involved Australian adolescents and included 260 Anglo‐Australian, 120 Greek, and 90 Southern Italian families. Regression models included terms to test for possible linear, interaction, and curvilinear associations between the sibling and family environment variables. The analysis suggested the propositions that: (a) parents from different ethnic groups create different learning environments for their children and that there are ethnic‐group variations in how children perceive their family environments, (b) there are ethnic‐group variations in relationships between sibling variables and adolescents’ perceptions of their parents’ support for learning, and (c) within ethnic groups the relationships between sibling variables and perceived parental support for learning differ, depending on whether the support of fathers or mothers is being considered.     

Correlates of Pro-Drinking Practices in Drinking Parents of Adolescents in Hong Kong

Introduction and Aims

Parental alcohol-related practices are important risk factors of adolescent drinking, but little is known about the factors associated with these parental pro-drinking practices (PPDPs). We investigated the correlates of 9 PPDPs in drinking parents of adolescents in Hong Kong.

Methods

A total of 2200 students (age 14.8±2.0; boys 63.2%) participated in a school-based cross-sectional survey in 2012. Analysis was restricted to 1087 (61.8%) students with at least 1 drinking parent as PPDPs were much more common in these families. Logistic regression was used to identify correlates of each PPDP.

Results

Among 1087 students, the prevalence of PPDPs ranged from 8.2% for training drinking capacity to 65.7% for seeing parents drink. Only 14.8% of students had not experienced any of these practices. More frequent maternal drinking predicted parental training of drinking capacity. Older age predicted helping parents buy alcohol and parental encouragement of drinking. Adolescent girls were more likely to have received parental training of drinking capacity than boys. Higher perceived family affluence was associated with hearing parents saying benefits of drinking, and helping parents open bottle and pour alcohol.

Conclusions

PPDPs were associated with parental drinking frequency and various socio-demographic factors. These results have implications on alcohol control programmes involving parents to tailor messages for reducing PPDPs based on the characteristics of adolescents and parents.     

Estimating final height from parental heights and sex in Taiwanese

We have developed a simple function for accurately estimating target height for use in evaluating growth and growth-promoting therapies in Taiwanese children. The heights of parents and their adult offspring born in the 1970s were determined in 1229 healthy families who accompanied another family member to our pediatric clinic. We directly measured the heights of the population-based cohort of adult offspring. The heights of their parents were based on self-report. Both the parents and their offspring were healthy. The increases in height between the two generations were 1.49-3.19 cm for boys and 2.03-2.61 cm for girls. These increases lie between those reported for Chinese children in Hong Kong (4.2-4.8 cm) and children in Sweden (0.7-1.0 cm). Final height was underestimated using the corrected midparental height method and was overestimated using the final parental height model developed from Swedish data. We developed a new linear model by fitting our data: boy height = 79.3 + 0.56 (midparental height); girl height = 35.2 + 0.76 (midparental height). The intercept and slope of the model are similar to those reported for Swedish girls but not to those reported for Swedish boys. Use of the new equations derived from our data may increase the accuracy of estimates of target height in Taiwanese children. The intermediate position of our fairly representative Taiwanese sample in both final height and generational increases in final height may reflect an intermediate stage between the Swedes and Hong Kong Chinese in the secular trend of heights.     

Ethical Issues in Adolescents' Sexual and Reproductive Health Research in Nigeria

There is increasing interest in the need to address the ethical dilemmas related to the engagement of adolescents in sexual and reproductive health (SRH) research. Research projects, including those that address issues related to STIs and HIV, adverse pregnancy outcomes, violence, and mental health, must be designed and implemented to address the needs of adolescents. Decisions on when an individual has adequate capacity to give consent for research most commonly use age as a surrogate rather than directly assessing capacity to understand the issues and make an informed decision on whether to participate in research or not. There is a perception that adolescents participating in research are more likely to be coerced and may therefore not fully comprehend the risk they may be taking when engaging in research. This paper examines the various ethical issues that may impact stakeholders' decision making when considering engaging adolescents in SRH research in Nigeria. It makes a case for lowering the age of consent for adolescents. While some experts believe it is possible to extrapolate relevant information from adult research, studies on ethical aspects of adolescents' participation in research are still needed, especially in the field of sexual and reproductive health where there are often differences in knowledge, attitudes and practices compared to adults. The particular challenges of applying the fundamental principles of research ethics to adolescent research, especially research about sex and sexuality, will only become clear if more studies are conducted.     

Hierarchical decision‐making balances current and future reproductive success

Parental decisions in animals are often context‐dependent and shaped by fitness trade‐offs between parents and offspring. For example, the selection of breeding habitats can considerably impact the fitness of both offspring and parents, and therefore, parents should carefully weigh the costs and benefits of available options for their current and future reproductive success. Here, we show that resource‐use preferences are shaped by a trade‐off between parental effort and offspring safety in a tadpole‐transporting frog. In a large‐scale in situ experiment, we investigated decision strategies across an entire population of poison frogs that distribute their tadpoles across multiple water bodies. Pool use followed a dynamic and sequential selection process, and transportation became more efficient over time. Our results point to a complex suite of environmental variables that are considered during offspring deposition, which necessitates a highly dynamic and flexible decision‐making process in tadpole‐transporting frogs.     

Developing Autonomy and Transitional Paternalism

Adolescents, in many jurisdictions, have the power to consent to life saving treatment but not necessarily the power to refuse it. A recent defence of this asymmetry is Neil Manson's theory of ‘transitional paternalism’. Transitional paternalism holds that such asymmetries are by‐products of sharing normative powers. However, sharing normative powers by itself does not entail an asymmetry because transitional paternalism can be implemented in two ways. Manson defends the asymmetry‐generating version of transitional paternalism in the clinical context, arguing that it maximizes respect for adolescent autonomy. This article offers an alternative argument in favour of the asymmetry‐generating form of transitional paternalism, one that makes appeal to obligations that individuals have to develop self‐governance in others. We should share normative powers asymmetrically in the clinical context for three reasons. First, the asymmetric version of transitional paternalism takes seriously duties to support adolescents’ developing autonomy, alongside other duties that adults have to young people. It does so by enabling young people to be involved in important decisions that they would otherwise be excluded from. This is of value because participation of this sort is central to the cultivation of their self‐governance. Second, only the asymmetric version gives young people a voice in respect of all clinical actions, and only the asymmetric version leaves open the possibility that the coarse lines of legislation might be ‘fine‐tuned’ in individual cases. Third, the asymmetric sharing of normative powers is consistent with the kind of social arrangements that best support autonomy.     

Eating Metropolitaneity: Hong Kong Identity in yumcha

In Hong Kong, yumcha as a pervasive form of eating in the public has become an institution which epitomises the diversity and inclusiveness that Hong Kong people think are quintessential to the civility and economic achievement of the metropolis. It stands out particularly as a practice that has come to represent both locally and overseas a Hong Kong culture which has previously been characterised as residual of ‘Chinese tradition’ and ‘Western customs’, and hence is virtually non-existent. This paper looks at the consumption of metropolitaneity and the culturalisation of the heunggongyan or Hong Kong personal identity in the form, content and social relations involved in yumcha. It points to the significance of yumcha as a key to understanding a collective identity which has become more and more apparent as Hong Kong people vehemently try to establish a city with its own culture, first against the colonial grip and then the return of sovereignty to China in 1997.     

Braving Difficult Choices Alone: Children's and Adolescents' Medical Decision Making

Objective

What role should minors play in making medical decisions? The authors examined children''s and adolescents'' desire to be involved in serious medical decisions and the emotional consequences associated with them.

Methods

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.

Results

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.

Conclusions

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.