Situation: A nurse works in the emergency room and pediatric ward of a provincial hospital, where a parent or other family member usually stays at each child's bedside and takes part in care. The parents of a 5-year-old with severe anemia refuse the blood transfusion ordered by the physician because of their religious beliefs. They are acting as the child's surrogate decision-makers. Which standard should guide a surrogate decision for this child?

A surrogate decides by substituted judgment when the client's own wishes are known, or by the client's best interests when they are not. A 5-year-old has never had the capacity to form such wishes, so the best-interests standard applies. The Code of Ethics also holds that when beliefs conflict with care, the client's welfare and safety take precedence, so the nurse advocates for the child.

Surrogate decision-making for a young child

When a child cannot make his or her own medical decisions, the law and ethics assign that role to a surrogate — usually a parent. The question is not whether parents may decide, but which ethical standard should guide the decision when the child has never been able to express his or her own wishes. For a 5-year-old, the answer is the best-interests standard.

The distinction between the two main surrogate standards matters for the PNLE and NCLEX-RN. Substituted judgment asks, “What would this patient have wanted?” It is used when the patient previously had decision-making capacity and expressed values or preferences — for example, an adult who once said, “I would never want a blood transfusion.” A 5-year-old has never had the developmental capacity to form such a considered wish about blood products, so substituted judgment cannot apply. Instead, the surrogate must ask, “What will most promote this child’s welfare and safety?” — that is, the best-interests standard ^[3].

The religious context of this scenario is a classic exam theme. Parents who are Jehovah’s Witnesses may refuse blood products for themselves, and that refusal is generally respected for competent adults ^[1]. However, when parents refuse transfusion on behalf of a child, the ethical calculus changes. The Japanese Joint Committee guideline states that the health and life of every child younger than 15 years should be guarded by the collective efforts of health, welfare, and advocacy institutions when a parent seeks to withhold transfusion therapy ^[2]. In other words, parental religious belief does not override the child’s right to life-saving care. The nurse’s role is to advocate for the child, which may mean involving the ethics committee, hospital administration, or legal mechanisms to authorize transfusion.

Watch out! Option 1 (parental preference) and Option 2 (parental autonomy) describe what the parents want, not what the child needs. They are distractors because they center the decision on the family’s beliefs rather than on the child’s welfare. Option 4 (substituted judgment) is tempting because it sounds like a surrogate standard, but it requires evidence of the patient’s own prior wishes — impossible for a 5-year-old.

Key point! The hierarchy is: if the patient’s own wishes are known, use substituted judgment; if they are not known or never existed, use best interests. For young children, best interests is the default standard ^[3]. Some scholars have proposed alternatives such as a “rational parent” or “not unreasonable” standard ^[3], but the prevailing ethical and legal standard for pediatric surrogate decisions remains best interests, and that is the standard licensing exams expect.

The nurse’s advocacy obligation follows directly from this standard. When a parent’s religious belief conflicts with medically necessary care, the child’s welfare and safety take precedence. The nurse should communicate this respectfully, explain the medical urgency, and escalate through the appropriate institutional channels rather than simply accepting the refusal.