participation in decisions could affect treatment outcome, and often children
play only a minor role in decision-making. Here, paediatricians role come to
offer children opportunities for participation and to guide parents as to how
their child could be involved (Ruhe et al., 2016).  In order to do assure adequate patient
participation, paediatricians and other professionals caring for children with
cancer need special training, such increase awareness of children’s individual
needs, capacities, and preferences and learning about strategies to involve
them according to these abilities and wishes (Ruhe et al., 2016). They
emphasized the level of children involvement should not only depend on
children’s maturity, but on their preferences too. Since wishes regarding
involvement can differ from child to child. In another study, Ruhe, et al.,
2016, said that participants children mentioned some obstacles that came out of
their involvement or non-involvement in their care, such as confusion of
information provided, sense of being overlooked, and pressure in making a
decision. Despite these challenges children considered their involvement as
important because they were the ones affected by the illness and treatment.

to International Society of Pediatric Oncology, Involving children in
communication about their illness and treatment decision is an ethical
obligation and demonstrates respect and value to their opinion. Children’s
participation in decisions could affect treatment outcome, and often children
play only a minor role in decision-making, and her paediatricians role come to
offer children opportunities for participation and to guide parents as to how
their child could be involved (Ruhe et al., 2016).  In order to do assure adequate patient
participation, paediatricians and other professionals caring for children with
cancer need special training, such increase awareness of children’s individual
needs, capacities, and preferences and learning about strategies to involve
them according to these abilities and wishes (Ruhe et al., 2016). They
emphasized also that, level of children involvement should not only depend on
children’s maturity, but also on their preferences, since wishes regarding
involvement can differ from child to child.

clinical trials progress in medical therapies for childhood cancer have been
achieved. It is known that treatment decision making in childhood cancer itself
is stressful situation for parents; then what if parents asked to enter their
child in a clinical research trials, this will be another stress added to them.
According to Shilling & Young, 2009, some parents saw trials as a threat to
their child or fear regretting their decision, whilst others saw trials as
offering hope better treatment for their child. The role of parents in trial
decision making is complex and it is a challenge for researchers in discussing
pediatric trials with parents to balance the tension surrounds them. Therefore,
researchers are required to support parent’s decision making appropriately and
guard against the possibility of regret (Shilling & Young, 2009). Subsequently, to conduct a trials with children it is required
to understand the special situations of parents and their particular need for
support to allow them to retain a sense that they have safeguarded their
child’s interest and secure the best outcome for them (Shilling & Young,
2009). In another study, Hoberman et al., 2013, highlighted an important
modifiable factors that influenced the consent process. Factors included the
involvement of a researcher who made them feel comfortable and proper
understanding of the study, the clarity of explanation on how research risk is
minimized, how participation affects standard of care, the right to withdraw at
any time, and the benefits to the child and other children. Additionally,
they found that, parents with high socioeconomic status and more educated
declined consent to their child’s participation and had high level of
decisional anxiety.

& Ganong, 2006, in a unique study, presented a special findings about
treatment decision making in single parents, and re-partnered parents suggesting
that, decision making process of single, divorced and re-partnered parents
might differ from that of married parents. They found that both biological
parent and step-parents assigned decision-making primacy exclusively to the
biological parent which is supporting the critical importance of treatment
decision making of parents of children with cancer as a natural extension of
their parental role.  As that, the parent
imperative for treatment decision making compelled custodial parents to reach
out to the co-parent, and the co-parent to step up to be actively involved in
the treatment decision-making process. They elucidated also, that majority of
co-parents stepped up to decision making, this behaviour reflected a natural
part of the parenting role, but when they did not, researchers assumed that
this reflected their previous level of parenting. Moreover, it was noted that
maternal gatekeeping plays a role in limiting paternal involvement however,
single mothers initially attempted to engage fathers in the treatment
decision-making process. From another perspective, Katherine & Lawrence,
2006, said that parent’s focus on the ill child created opportunities for
parenting collaboration and cooperation that had not always been present prior
to the child’s diagnosis. But unfortunately, normalization for parents in their
study which consisted returning parents’ previous patterns of interaction with
their former partners was not effective. Study mentioned that separated
biological parents also reported increased difficulty interacting with
step-parents than did parents who had separated years previously.

are eligible to make medical decisions on behalf of their children, moreover;
they also have the right to refuse or discontinue treatments, even those that
may cause life-threatening. Hord et al., 2006, argued that, since the cure rates form any childhood malignancies are more than
50% with standard therapy regimens, with holding treatment can be a dif?cult
ethical dilemma for the treatment providers who should seek legal recourse in
such case. They added, it is physician’s responsibility to the patient to
establish the course of treatment that will provide the best opportunity for
long-term survival, but when dealing with patients with poor prognosis,
limiting medical therapy is reasonable, ethical, and morally defensible because
the burdens of therapy may outweigh the bene?ts, and parents must consider
quality of life.

many studies have highlighted several factors that might influence parental
treatment decision making for children with cancer. Pyke-Grimm et al., 2006,
elucidated some factors that were frequently identified to affect parent’s
decision such: parent’s relationship with physician, nature of communication,
trust in the physician, parents and physician knowledge and experience. According
to Pyke-Grimm et al., 2006, most of the parents preferred collaborative role
with physician in treatment decision making, and this reflecting the importance
of parent’s relationship with the physician in determining their role in
treatment decision. Better communication between parents and physicians and
other health care providers found to be associated with improved psychological
adjustment and treatment adherence. Also, this study referred to parents trust
in physician as an important factor in the situation of treatment decision
making process. It is pointed that parent’s decision about their child’s cancer
treatment was influenced by trust in physician. At last, study listed
physician’s superior knowledge as an important factor in parents’ decision
process. Parents’ participation in decisions making was influenced by their
awareness of doctor’s level of knowledge, and experience, believing that
physician having knowledge, and experience were expert at dealing with cancer
(Pyke-Grimm et al., 2006. According to Miller & Nelson 2012, parents’
demographic characteristics such as education, income, race, gender; and
previous experience with a similar decision treatment decisions for their
children are factors affecting parents’ decision-making. They found that, low participation
of parents in treatment process was associated with lower education, male
gender, minority status, and not having previous experience with a similar

to previous view, parents are considered the key part in childhood cancer
medical decision making. Many strategies
and policies have been developed to facilitate parental decision making process
such as informed consent. It is legally allowed for parents to provide informed
permission for their children. Several literatures showed that making treatment
decision is one of the most major challenges faced children’s parents with
cancer.  Definitely, it is a difficult
responsibility for parents to make decision that will affect their child health
and life span. According to Stewart, Pyke-Gerimm, & Kelly 2012, making the right
decision is a nature extension of the parental role, of acting in one’s child’s
best interest and ensuring the best possible results. They found that uncertainty
was characterized as one of the most stressful aspects of parenting a seriously
ill child. Whereas uncertainty related to limited knowledge and experience can
often be improve. It is possible to say that, the nature of parents’
relationships with the physician responsible for child’s care, was central to
the decision making process. Therefore, physician attributes that convey
trustworthiness found to ameliorate the parents emotional stress associated
with uncertainty and decision responsibility (Stewart,
Pyke-Gerimm, & Kelly, 2012). Furthermore, McKenna et al., 2009, identified
parental perceptions of their own involvement in the decision to enrol their
child on to a speci?c cancer treatment protocol. They found that, parents were
happier with their decision when they felt that they had made an informed
choice and received the right amount of information regarding treatment
options, while decision-making process was more dif?cult when parents were
unsure what to do. Accordingly, information and support tailored to parents’
speci?c needs may therefore enhance satisfaction with clinical decision making
and reassure parents about decisions made in the long-term interest of their
child’s health. Another important finding was that, parent’s satisfaction with
both the decision-making process, and their con?dence in the decision was
impacted with accessibility of treating physician, information provided and
degree of support afforded to them. (McKenna, et al., 2012. On another study, Mack,
et al., 2011, evaluated the extent to which parents’ roles in decision making
in the ?rst year of their child’s cancer treatment matched their preferences. They
found that, the majority of the studied parents were able to have their desired
level of involvement in decision making for their child’s cancer, but nearly a
quarter were less involved in decision making than they wished, a circumstance
that was associated with decreased trust of the child’s physician.

decision is a critical and complex task especially when providing care for
pediatric oncology patients. Physicians are facing many challenges when
identifying and selecting from available treatment options. Ethical practice of
medicine involves a set of responsibilities, namely providing maximum benefit
and avoiding harm, relief of symptoms, and saving and/or prolonging life
(Friebert & Kodish, 1999). Many ethical theories argued that physicians must
provide information for patients and their families to enable them to take
their own decision rather than making decisions for patients (Simons et al.,
2006). Whitney et al., (2006), integrated the ethical theory with the concrete
realities of clinical medicine as physicians strive to ?nd the right treatment
choice for oncology child, and they suggested that physicians have decisional
priority when there is one clear best medical option, whether the chance of
cure is signi?cant or vanishingly small. Empirically and ethically, physician
role is to assume decisional priority because of his or her knowledge, based on
the best available evidence as applied to the child’s circumstance, indicates
that this is the most effective treatment approach priority, and then comes the role of the parents to exercise
decisional and legal authority (Whitney et al., 2006). In my point of view, I
believe this is an ethically appropriate division of the work of decision

cancer is the cancers that occurs in children younger than 18 years. Although
cancer is uncommon in children, it is has been classified the leading cause of
death in children under 15 years, despite many medical interventions available.
There are no known causes of childhood cancer, and it occurs across all ethnic
groups; moreover, some children are even born with cancer. A child’s cancer
diagnosis creates major emotional distress, and affects personal and family
equilibrium. After the diagnosis of cancer it begins the most critical and
difficult step; it is a treatment decision making of a life-threatening illness
and risks associated with treatment. For children with serious illness such as
cancer, the clinical decision making is a significant challenge for physicians,
parents, and patients. It is accompanied with unique ethical issues (Whitney et
al., 2006). Therefore, ethics practice is necessary during clinical decision
making in pediatric oncology. Accordingly, this paper will be focused on a
number of key themes: decision making in pediatric oncology by physicians; parents’
participation in treatment decisions; factors that might affect parent’s
decisions; participation of child in clinical trials and refuse of treatment by
parents. I will then turn my attention to another ethical dilemmas such as involving
pediatric patient in decision making; preservation of fertility; end of life
preference and choosing a do not resuscitate. (DNR). Finally, I will offer my
own thoughts and hypothesis.


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