Respecting parental decisions: where should you draw the line?

05 June 2019

Official health guidelines and recommendations are backed by a wealth of evidence, so when parents reject that advice, how do you respond? Here are three views...

Deborah Cookson

District manager,
Dartford Health Visiting Team

When respecting parental decisions, where do CPs draw the line?

We can only judge at the time, when we need to stand back. For example, the reason for not vaccinating their children can differ from one family to the next. Sometimes a sleep-deprived parent will decide to introduce solid food early because they have been told their child will stop waking in the night for a milk feed – the idea of a full night’s sleep outweighs everything. Other times, decisions can be based on advice from family members. These situations are what health visitors regularly face.

I ask at the time, what are this family’s priorities? What information is this decision based on and are any factors influencing it? Am I listening? What other support can I offer? Our messages are evidence-based and in line with local and national agendas, but the reality is, despite careful navigation and my best efforts, the priorities of parents may not be the same as mine. The decisions they make will be for the good of themselves and their children, not my agenda.

I also need to consider are parents ready to make changes or take my advice? Of course, there may be times that the decision a parent makes falls into the safeguarding arena and as HVs we must act appropriately.

But if I know I have entered a home in a non-judgemental and open way, listened, offered my support and advice, and I have not been alerted to any safeguarding concerns, then it is not my role to do anything other than respect the decision a parent makes.

Melanie Kwok

Health visitor,
Leicestershire Partnership NHS Trust

As a SCPHN HV, a lot of my job involves giving health advice to educate and empower the parents to inform their own evidence-based decision-making. This is often on topics such as introducing solids, safe sleeping and advice on immunisations. But the main word to take note of is ‘advice’. We cannot turn up at a family’s house during dinner time to make sure parents aren’t introducing solids before six months, or in the middle of the night to make sure that they are following safe-sleeping guidelines. Likewise, we cannot physically take every family to have their children vaccinated.

I’ve recently met parents who have chosen to introduce solids early or who have decided against vaccinations. At this point, I believe the role of an SCPHN should not be to sit back and do nothing. For the child’s best interests, the SCPHN should have conversations with the parents to explore the reasons behind their choices and to make sure they are aware of the possible risks. Had they been misinformed or received out-dated health advice?

The only way that the health advice we give will make a positive difference is if the parents trust us. I firmly believe in the importance of building good relationships with parents. Once this trust is established, I’ve found that parents are more likely to be receptive.

However, in a situation where the parents’ choices would put the child at immediate risk of severe harm, an SCPHN should definitely take the appropriate actions to safeguard the child.

Jessica Jackson

Research nurse, University of Derby; health visitor, Derbyshire Healthcare NHS Foundation Trust

We are accountable to ethical codes and for safeguarding. But when making decisions we must also be sensitive to parenting styles, traditions and beliefs

Balancing individual choice with the greater good is a constant ethical dilemma in public health – for example, the decision to add fluoride to water or banning smoking in public places. The daily balancing act of respecting parental decisions and intervening with targeted health interventions is even more nuanced.

The work we do aims to benefit our local populations and society as a whole. However, the relationship between the community practitioner and the community is complex. When addressing health needs, we are accountable to ethical codes and for safeguarding vulnerable children. But when making decisions we must also be sensitive to parenting styles, family traditions, cultural values and beliefs. Instructing parents what to do and think regardless of these considerations could be counterproductive to developing relationships. It could also close the door to the most vulnerable communities altogether.

Nor are we exempt from our own values and beliefs. What is acceptable to us may not be acceptable to another. We may try to ensure our personal opinions do not influence our practice, but we cannot fully eliminate this bias within our assessments. Regular supervision is a way of recognising how our values could influence our decisions to intervene with certain families and not others.

By collectively acknowledging the diversity of the community practitioner workforce itself, we can also think about how historically this might have shaped the collective approach of the service.

We are often the first healthcare professionals that families will turn to when they need up-to-date evidence, guidance and advice. To achieve the maximum benefit for the communities we serve, balancing and nurturing the practitioner/community relationship needs constant reflection.