When We Decide For You: Assessing the Impact of Binding Decisions in Pediatrics and the Future of the Texas Advance Directives Act

The Texas Advance Directives Act (TADA) became law in 1999 and includes a provision permitting hospital ethics committees to issue binding decisions in the event of intractable disagreements between physicians and surrogates. The law is unique within the United States and remains closely watched beyond the Texas border. Once hoped to provide an extra-judicial means of settling some of medicine's most difficult disputes, the provision has become a divisive policy and frequently sparks debate, litigation, and media attention—especially when children are involved.

This paper will discuss the impact of TADA in pediatric health care. Information gathered from the largest pediatric hospitals in Texas, and authors of TADA, provide insight to how binding reviews affect families, clinicians, ethics committees, and institutions. Characterizations of the law include "the last resort," "never again," and "the nuclear option." Stories of broken trust, prolonged litigation, public outcry, and emotional scarring pervade. Simultaneously, TADA remains endorsed by numerous professional organizations, and is defended with, "I hope we never have to use it, but I'm grateful it's there," and "I would never want it repealed."

Is TADA the future for dispute resolution in health care, is it a failed experiment to be relegated to the past, or merely too blunt an instrument for the subtleties of pediatrics? Following an overview of firsthand accounts from binding decisions, this paper will illuminate the challenging questions that emerged in the inquiry, and engage the audience in discussion about the future of TADA in Texas pediatrics and beyond.

Stephanie Kukora, MD – Department of Pediatrics – Children’s Mercy Kansas City; Dawn Hood Patterson, PhD, MDiv, HEC-C – Children’s Mercy Bioethics Center – Children’s Mercy Kansas City