P3A153: Does the Abused Infant Have a Voice?

Introduction: Bioethics presumes parents make best-interest decisions for their children. In non-accidental parental trauma to an infant, conflicting priorities arise, that may preclude the child receiving the best parental decisions. The legal system protects adults’ rights through legal representation and a child's rights through guardians ad litem, who may lack expertise and hesitate to speak forcefully on behalf of the infant. We present two similar cases separated by 35 years to highlight the differences in process and outcome, highlighting palliative care’s advocacy role in child abuse.

Case Description: In Minnesota vs. Steinhaus (1986), a defendant was found guilty of striking his crying 5-wo infant, producing devastating brain damage. Left vegetative after months in the PICU, the infant required tracheostomy and G-tube. The father’s attorney argued initially for the preservation of the infant's life at all costs despite the mother's request to allow death. The court forbade DNR orders recommended by medical specialists and mandated full support. Following adjudication on battery charges and the avoidance of a manslaughter conviction, had the child died, the defense recanted its position and stated they no longer had an interest in the outcome for the infant. He died peacefully in hospice care many months later.

In 2022, a 7-wo was beaten by his father, presenting in extremis with severe skeletal, cervical, and brain trauma. The mother requested comfort care only, but the father's attorney insisted on all life sustaining measures, attempting to avoid his client facing a manslaughter charge. The child experienced worsening spasticity, neurostorming and sequelae of the trauma, while the mother's effort to obtain custody was delayed by logistical hurdles. Following the mother's retaining private representation, the court granted her custody, terminating the father's rights. Artificial life support was discontinued with medical oversight and comfort medications, and he died of his brain injury several days later.

Discussion: These two cases of infant battery highlight the difficulty clinicians face in making appropriate and timely decisions for severely abused infants. For these infants, the abusing parent's legal defense to minimize punishment clashed with the best interest of the child as expressed by the non-abusing parent and supported by medical opinion. The child in 1986 was subjected to burdensome, invasive medical procedures to allow the father's legal wrangling to run its course. In the second case, engagement of suitable representation allowed the resolution of the custody issue, so that appropriate medical decisions could be made. In both cases, the legal proceedings imposed burdensome months of uncomfortable, invasive medical care until the children were allowed the right to die of their extensive injuries.

Conclusion: Palliative care should play an important and decisive role in helping advocate for the rights and voice of the infant in cases of abuse.