World Medical Association, Declaration of Ottawa on the Right of the Child for Health Care (1998)

Adopted by the 50th World Medical Assembly Ottawa, Canada, October 1998



PREAMBLE
1. The health care of a child, whether at home or in hospital, includes medical, emotional, social and financial aspects which interact in the healing process and which require special attention to the rights of the child as a patient.
2. Article 24 of the 1989 United Nations Convention on the Rights of the Child recognises the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health, and states that nations shall strive to ensure that no child is deprived of his or her right of access to such health care services.
3. In the context of this Declaration a child signifies a human being between the time of birth and the end of her/his seventeenth year, unless under the law applicable in the country concerned children are legally recognized as adults at some other age.

GENERAL PRINCIPLES
4. Every child has an inherent right to life, as well as the right of access to the appropriate facilities for health promotion, the prevention and treatment of illness and the rehabilitation of health. Physicians and other health care providers have a responsibility to acknowledge and promote these rights, and to urge that the material and human resources be provided to uphold and fulfil them. In particular every effort should be made:
i) to protect to the maximum extent possible the survival and development of the child, and to recognise that parents (or legally entitled representatives) have primary responsibility for the development of the child and that both parents have common responsibilities in this respect;
ii) to ensure that the best interests of the child shall be the primary consideration in health care;
iii) to resist any discrimination in the provision of medical assistance and health care from considerations of age, gender, disease or disability, creed, ethnic origin, nationality, political affiliation, race, ***ual orientation, or the social standing of the child or her/his parents or legally entitled representatives;
iv) to attain suitable pre-natal and post-natal health care for the mother and child;
v) to secure for every child the provision of adequate medical assistance and health care, with emphasis on primary health care, pertinent psychiatric care for those children with such needs, pain management and care relevant to the special needs of disabled children;
vi) to protect every child from unnecessary diagnostic procedures, treatment and research;
vii) to combat disease and malnutrition;
viii) to develop preventive health care;
ix) to eradicate child abuse in its various forms; and
x) to eradicate traditional practices prejudicial to the health of the child.

SPECIFIC PRINCIPLES
Quality of care
5. Continuity and quality of care should be ensured by the team providing health care for a child.
6. Physicians and others providing health care to children should have the special training and skills necessary to enable them to respond appropriately to the medical, physical, emotional and developmental needs of children and their families.
7. In circumstances where a choice must be made between child patients for a particular treatment which is in limited supply, the individual patients should be guaranteed a fair selection procedure for that treatment made on medical criteria alone and without discrimination.

Freedom of choice
8. The parents or legally entitled representatives, or the child herself/himself if she/he is of sufficient maturity, should be able: to choose freely and to change the child's physician; to be satisfied that the physician of choice is free to make clinical and ethical judgements without any outside interference; and to ask for a second opinion of another physician at any stage.

Consent and self-determination
9. A child patient and her/his parents or legally entitled representatives have a right to active informed participation in all decisions involving the child's health care. The wishes of the child should be taken into account in such decision making, and should be given increasing weight dependant on her/his capacity of understanding. The mature child, in the judgement of the physician, is entitled to make her/his own decisions about health care.
10. Except in an emergency (see par 12 below), informed consent is necessary before beginning any diagnostic process or therapy on a child, especially where it is an invasive procedure. In the majority of cases the consent shall be obtained from the parents or legally entitled representatives, although any wishes expressed by the child should be taken into account before consent is given. However, if the child is of sufficient maturity and understanding, the informed consent shall be obtained from the child herself/himself.
11. In general, a competent child patient and her/his parents or legally entitled representatives are entitled to withhold consent to any procedure or therapy. While it is presumed that parents or legally entitled representatives will act in the best interests of the child, occasionally this may not be so. Where a parent or legally entitled representative refuses consent to a procedure and/or treatment, without which the child's health would be put in grave and irreversible danger and to which there is no alternative within the spectrum of generally accepted medical care, the physician should obtain the relevant judicial or other legal authorisation to perform such a procedure or treatment.
12. If the child is unconscious, or otherwise incapable of giving consent, and a parent or legally entitled representative is not available, but a medical intervention is needed urgently, then specific consent to the intervention may be presumed, unless it is obvious and beyond any reasonable doubt on the basis of a previous firm expression or conviction that consent to the intervention would be refused in the particular situation (subject to the proviso detailed in paragraph 7 above).
13. A child patient and her/his parents or legally entitled representatives are entitled to refuse to participate in research or in the teaching of medicine. Such refusal must never interfere with the patient-physician relationship or jeopardise the child´s medical care or other benefits to which she/he is entitled.

Access to information
14. The child patient and (except in the circumstances outlined in paragraph 18 below) her/his parents or legally entitled representatives are entitled to be fully informed about her/his health status and medical condition, provided this would not be contrary to the interests of the child. However, confidential information in the child's medical record about a third party should not be provided to the child, the parents or the legally entitled representatives without the consent of that third party.
15. Any information should be provided in a manner appropriate to the culture and to the level of understanding of the recipient. This is particularly important in the case of information provided to the child, who should have the right of access to general health information.
16. Exceptionally, certain information may be withheld from the child, or her/his parents or legally entitled representatives, when there is good reason to believe that this information would create a serious hazard to the life or health of the child or to the physical or mental health of a person other than the child.

Confidentiality
17. In general the obligation of physicians and other health care workers to maintain the confidentiality of identifiable personal and medical information of patients (including information about health status, medical condition, diagnosis, prognosis, and treatment) applies as much in the case of child patients as it does for those who are adult.
18 The child patient mature enough to be unaccompanied at a consultation by her/his parents or legally entitled representatives is entitled to privacy and may request confidential services. Such a request should be respected, and information obtained during such a consultation or counselling session should not be disclosed to the parents or legally entitled representatives except with the consent of the child, or in circumstances where adult confidentiality can be breached. In addition, where the attending physician has strong reason to conclude that, despite unaccompanied attendance, the child is not competent to make an informed decision about treatment, or that without parental guidance or involvement the child's health would be put in grave and irreversible danger, then in exceptional circumstances, the physician may disclose to the parents or legally entitled representatives confidential information gained during an unaccompanied attendance. However, the physician should first discuss with the child her/his reasons for doing so and attempt to persuade the child to agree to this action.

Admission to Hospital
19. A child should be admitted to hospital only if the care he/she requires cannot be provided at home or on an outpatient basis.
20. A child admitted to hospital should be accommodated in an environment designed, furnished and equipped to suit her/his age and health status, and a child should not be admitted to adult accommodation except in special circumstances dictated only by her/his medical condition, e.g. where the child is admitted for childbirth or termination of pregnancy.
21. Every effort should be made to allow a child admitted to hospital to be accompanied by her/his parents or parent substitutes, who should be provided, where relevant, with appropriate accommodation in or near the hospital at no or minimal cost and with the opportunity to be absent from their place of work without prejudice to their continued employment.
22. Every child in hospital should be allowed as much outside contact and visiting as possible consistent with good care, without restriction as to the age of the visitor, except in circumstances where the attending physician has strong reason to believe that visiting would not be in the best interests of the child herself/himself.
23. Where a child of relevant age has been admitted to hospital her/his mother should not be denied the opportunity to breast-feed, unless there is a positive medical contra-indication to such.
24. A child in hospital should be afforded every opportunity and facility appropriate to her/his age for play, recreation and the continuation of education. To facilitate the latter the provision of specialised teachers should be encouraged or the child afforded access to appropriate distance learning programmes.

Child Abuse
25. All appropriate measures must be taken to protect children from all forms of neglect or negligent treatment, physical and mental violence, coercion, maltreatment, injury or abuse, including ***ual abuse. In this context attention is drawn to the provisions of the WMA's Statement on Child Abuse and Neglect (WMA Document 17.W).

Health Education
26. Parents, and children appropriate to their age and/or development , should have access to, and full support in the application of, basic knowledge of child health and nutrition, including the advantages of breast-feeding, and of hygiene, environmental sanitation, the prevention of accidents, and ***ual and reproductive health education.

Dignity of the patient
27. A child patient should be treated at all times with tact and understanding and with respect for her/his dignity and privacy.
28. Every effort should be made to prevent, or if that is not possible to minimise, pain and/or suffering, and to mitigate physical or emotional stress in the child patient.
29. The terminally ill child should be provided with appropriate palliative care and all the assistance necessary to make dying as comfortable and dignified as possible.

Religious assistance
30. The terminally ill child should be provided with appropriate palliative care and all the assistance necessary to make dying as comfortable and dignified as possible.