{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,10]],"date-time":"2026-11-10T13:26:58Z","timestamp":1794317218332,"version":"4.9.0"},"reference-count":22,"publisher":"American Academy of Pediatrics (AAP)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,11,1]]},"abstract":"<jats:p>More effective and less toxic therapies are welcomed by clinicians and families and are the rationale and raison d\u2019\u00eatre for well-designed clinical trials. This is especially true for life-threatening diseases like childhood cancer. When parents opt for an existing and good treatment, rather than accept a new and better treatment of a child with cancer, clinicians may struggle to accept the parents\u2019 refusal. In considering such a refusal, should parental reasons matter? In this situation, should clinicians be more forceful in attempting to sway the parents to accept a novel and improved therapy? How does the sincerity of the therapeutic relationship, especially trust, factor into this calculus? In the following ethics rounds, stemming from a 2025 American Society for Bioethics and Humanities Meeting session, the commentators draw on their diverse background as pediatric clinicians, bioethicists, philosophers, and educators to navigate this challenging situation. They consider the intersection of evolving standards of care, parental authority, and clinician influence, with particular attention to communication and trust, emphasizing active listening and attending to what parents have to say.<\/jats:p>","DOI":"10.1542\/peds.2026-076448","type":"journal-article","created":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T00:03:03Z","timestamp":1791244983000},"source":"Crossref","is-referenced-by-count":0,"title":["Parental Refusal of the Best Treatment: Nudges and Trust in Pediatrics"],"prefix":"10.1542","volume":"158","author":[{"given":"Yoram","family":"Unguru","sequence":"first","affiliation":[{"name":"1Division of Pediatric Hematology\/Oncology, The Herman and Walter Samuelson Children\u2019s Hospital at Sinai, Baltimore, Maryland"},{"name":"2Johns Hopkins University, Berman Institute of Bioethics, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas","family":"Diekema","sequence":"additional","affiliation":[{"name":"3Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington"},{"name":"4Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children\u2019s Research Institute, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer Blumenthal","family":"Barby","sequence":"additional","affiliation":[{"name":"5Baylor College of Medicine, Houston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liza-Marie","family":"Johnson","sequence":"additional","affiliation":[{"name":"6Department of Oncology and The Bioethics Program, St. Jude Children\u2019s Research Hospital, Memphis, Tennesse"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2026,10,6]]},"reference":[{"issue":"13","key":"2026111007580271600_r1","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.1200\/JCO.20.00494","article-title":"Excellent outcomes with reduced frequency of vincristine and dexamethasone pulses in standard-risk B-lymphoblastic leukemia: results From Children\u2019s Oncology Group AALL0932","volume":"39","author":"Angiolillo","year":"2021","journal-title":"J Clin Oncol."},{"key":"2026111007580271600_r2","article-title":"PDQ Pediatric Treatment Editorial Board. PDQ Childhood Acute Lymphoblastic Leukemia Treatment"},{"issue":"11","key":"2026111007580271600_r3","doi-asserted-by":"crossref","first-page":"2382","DOI":"10.1038\/s41375-024-02395-4","article-title":"Determinants of survival after first relapse of acute lymphoblastic leukemia: a Children\u2019s Oncology Group study","volume":"38","author":"Rheingold","year":"2024","journal-title":"Leukemia."},{"issue":"9","key":"2026111007580271600_r4","doi-asserted-by":"crossref","first-page":"875","DOI":"10.1056\/NEJMoa2411680","article-title":"Blinatumomab in standard-risk B-cell acute lymphoblastic leukemia in children","volume":"392","author":"Gupta","year":"2025","journal-title":"N Engl J Med."},{"key":"2026111007580271600_r5","doi-asserted-by":"crossref","DOI":"10.1017\/CBO9781139171946","volume-title":"Deciding for Others: The Ethics of Surrogate Decision Making","author":"Buchanan","year":"1990"},{"key":"2026111007580271600_r6","volume-title":"Principles of Biomedical Ethics","author":"Beauchamp","year":"2019","edition":"8th ed"},{"issue":"4","key":"2026111007580271600_r7","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1007\/s11017-004-3146-6","article-title":"Parental refusals of medical treatment: the harm principle as threshold for state intervention","volume":"25","author":"Diekema","year":"2004","journal-title":"Theor Med Bioeth."},{"issue":"3","key":"2026111007580271600_r8","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1086\/JCE2019303207","article-title":"Decision making on behalf of children: understanding the role of the harm principle","volume":"30","author":"Diekema","year":"2019","journal-title":"J Clin Ethics."},{"issue":"1","key":"2026111007580271600_r9","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1177\/1477750915622033","article-title":"The zone of parental discretion: an ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child","volume":"11","author":"Gillam","year":"2016","journal-title":"Clin Ethics."},{"key":"2026111007580271600_r10","doi-asserted-by":"crossref","DOI":"10.7551\/mitpress\/13785.001.0001","volume-title":"Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics","author":"Blumenthal-Barby","year":"2021"},{"key":"2026111007580271600_r11","volume-title":"Nudge","author":"Thaler","year":"2021"},{"issue":"2","key":"2026111007580271600_r12","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1002\/hast.837","article-title":"Nudge or grudge? Choice architecture and parental decision-making","volume":"48","author":"Blumenthal-Barby","year":"2018","journal-title":"Hastings Cent Rep."},{"issue":"4","key":"2026111007580271600_r13","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1353\/ken.2012.a495158","article-title":"Between reason and coercion: ethically permissible influence in health care and health policy contexts","volume":"22","author":"Blumenthal-Barby","year":"2012","journal-title":"Kennedy Inst Ethics J."},{"issue":"1","key":"2026111007580271600_r14","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.pcl.2023.08.001","article-title":"Shared decision-making in pediatrics","volume":"71","author":"Sawyer","year":"2024","journal-title":"Pediatr Clin North Am."},{"key":"2026111007580271600_r15","volume-title":"2025 Edelman Trust Barometer Global Report: Trust and the Crisis of Grievance","author":"Edelman Trust Institute","year":"2025"},{"key":"2026111007580271600_r16","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1016\/bs.irn.2018.07.020","article-title":"Fridman! Ashton-James CE. Choose your words wisely: the impact of message on patients\u2019 responses to treatment advice","volume":"139","author":"Glare","year":"2018","journal-title":"Int Rev Neurobiol."},{"issue":"1","key":"2026111007580271600_r17","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1007\/s10865-020-00171-0","article-title":"Gain-loss framing and patients\u2019 decisions: a linguistic examination of information framing in physician-patient conversations","volume":"44","author":"Fridman","year":"2021","journal-title":"J Behav Med."},{"issue":"1","key":"2026111007580271600_r18","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1001\/jama.2019.19003","article-title":"Practices to foster physician presence and connection with patients in the clinical encounter","volume":"323","author":"Zulman","year":"2020","journal-title":"JAMA."},{"issue":"9","key":"2026111007580271600_r19","doi-asserted-by":"crossref","first-page":"1100","DOI":"10.1001\/jama.293.9.1100","article-title":"Clinical empathy as emotional labor in the patient-physician relationship","volume":"293","author":"Larson","year":"2005","journal-title":"JAMA."},{"issue":"6","key":"2026111007580271600_r20","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1001\/jamasurg.2016.5674","article-title":"A framework to improve surgeon communication in high-stakes surgical decisions: best case\/worst case","volume":"152","author":"Taylor","year":"2017","journal-title":"JAMA Surg."},{"issue":"9","key":"2026111007580271600_r21","doi-asserted-by":"crossref","first-page":"1805","DOI":"10.1111\/jgs.13615","article-title":"\u201cBest case\/worst case\u201d: qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions","volume":"63","author":"Kruser","year":"2015","journal-title":"J Am Geriatr Soc."},{"issue":"9","key":"2026111007580271600_r22","doi-asserted-by":"crossref","first-page":"e2531199","DOI":"10.1001\/jamanetworkopen.2025.31199","article-title":"Critical care physicians\u2019 perspectives on nudging in communication","volume":"8","author":"Soled","year":"2025","journal-title":"JAMA Netw Open."}],"container-title":["Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2026-076448\/1973594\/pediatrics.2026076448.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2026-076448\/1973594\/pediatrics.2026076448.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,11,10]],"date-time":"2026-11-10T12:58:10Z","timestamp":1794315490000},"score":1,"resource":{"primary":{"URL":"https:\/\/publications.aap.org\/pediatrics\/article\/158\/5\/e2026076448\/210731\/Parental-Refusal-of-the-Best-Treatment-Nudges-and"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,6]]},"references-count":22,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,10,6]]},"published-print":{"date-parts":[[2026,11,1]]}},"URL":"https:\/\/doi.org\/10.1542\/peds.2026-076448","relation":{},"ISSN":["0031-4005","1098-4275"],"issn-type":[{"value":"0031-4005","type":"print"},{"value":"1098-4275","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,6]]},"article-number":"e2026076448"}}