Background: Tdap vaccine receipt in the immediate postpartum period has not been well studied. Objectives: We study factors associated with Tdap vaccine receipt during both pregnancy and the immediate postpartum period. Design: Retrospective study of 2844 pregnant patients that delivered. Methods: Factors from demographics, medical history, previous obstetric history, prenatal care, and previous vaccination history were included. Results: 39.7% of patients received the Tdap vaccine, 39.5% received the Tdap vaccine prior to delivery, and 20.8% received the Tdap vaccine between delivery and discharge. Increased age (relative risk ratio (RRR): 0.98, 95% CI: 0.96, 0.99, p = 0.01) and lower number of prenatal care visits of fewer than 11 (RRR: 0.51, 95% CI: 0.41, 0.64, p < 0.001) were associated with decreased likelihood of vaccine receipt before delivery. Spanish language (before: RRR: 2.35, 95% CI: 1.69, 3.25, p < 0.001; after: RRR: 1.68, 95% CI: 1.13, 2.49, p = 0.01) and South Asian languages (before: RRR: 1.55, 95% CI: 1.03, 2.32, p = 0.04; after: RRR: 1.69, 95% CI: 1.06, 2.69, p = 0.03) had similar patterns for increased likelihood of Tdap vaccine receipt before and after delivery. Race/ethnicity of Hispanic (RRR:1.84, 95% CI: 1.31, 2.59, p = 0.001), Asian (RRR:1.65, 95% CI: 1.22, 2.22, p = 0.001), and receipt of influenza vaccine during current pregnancy (RRR: 1.58, 95% CI: 1.31, 1.91, p < 0.001) were associated with increased likelihood before delivery. Conclusion: Prenatal Tdap vaccination is the best way to prevent infection with B. pertussis. Postpartum Tdap vaccination provides some protection for those declining prenatal vaccination. We recommend that clinicians recognize that there are different patterns for Tdap vaccine receipt before and after delivery and tailor Tdap vaccine counseling based on these patterns.

Background:Risk assessment tools are used by clinicians to predict which patients might have excessive bleeding. We studied the association between a peripartum hemorrhage risk assessment score using peripartum quantified blood loss (QBL) among those with vaginal deliveries who are often at lower risk for peripartum hemorrhage. Methods:In this retrospective analysis of 1221 patients with term vaginal deliveries at a public New York City hospital, the Association of Women's Health, Obstetric and Neonatal Nurses (AWOHNN) risk assessment tool was used to categorize patients as low risk, medium risk, or high risk for postpartum hemorrhage. Results:Low-risk scores were present in 925 (75.8%) patients, medium-risk scores in 268 (21.9%) patients, and high-risk scores in 28 (2.3%) patients. Outcome variables consisted of QBL (M = 213.8, SD = 215.00 mL), QBL ≥ 500 mL (n = 89, 7.3%), and ratio of postdelivery hematocrit to predelivery hematocrit (M = 0.9, SD = 0.08). High-risk score (B = 0.14, SE = 0.07, P = 0.04) but not medium-risk score was significantly associated with increased QBL as compared to low-risk score. Body mass index (BMI) measured as a continuous variable was significantly associated with increased QBL (B = 0.004, SE = 0.002, P = 0.049). However, BMI measured as a categorical variable using the AWOHNN cutoff score of >35 was not significantly associated with QBL. AWOHNN score was not significantly associated with QBL ≥ 500 mL or with the ratio of postdelivery hematocrit with predelivery hematocrit. Conclusion:We recommend revising the AWOHNN measure to better reflect medium risk and to consider a different approach for BMI use as part of the AWOHNN risk score.

Objectives: Socioeconomic characteristics may be associated with cesarean section (CS) rates. We probe the relationship between socioeconomic variables and primary cesarean section (PCS) by studying indicators of socioeconomic status (SES) in a population-based study in New York City. Methods: This was a retrospective study of all 80,506 women in New York City who gave birth to a live child during 2018, and who met inclusion and exclusion criteria. Data were drawn from the New York City Department of Health and Mental Hygiene and the US Census. The main outcome measure was performance of PCS as compared with vaginal birth. Results: Approximately 21% of neonates were delivered by PCS. Multivariate multilevel mixed-effects logistic regression analysis showed higher odds for PCS for women with an upper-middle class median household income of US$108,500 to $380,499 (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07-1.76, P = 0.001), and the percentage enrolled in the Supplemental Nutrition Assistance Program (OR 1.01, 95% CI 1.001-1.012, P = 0.02). Lower odds for PCS occurred for all middle-class categories of per capita income: US$32,500 to $54,499 (OR 0.91, 95% CI 0.84-0.99, P = 0.02), US$54,500 to $108,499 (OR 0.76, 95% CI 0.66-0.88, P < 0.001), and US$108,500 to $380,499 (OR 0.80, 95% CI 0.66-0.96, P = 0.02). No significant association occurred for women receiving public assistance. Conclusions: Patient preferences in favor or against CS may be related to SES. There may be conflicts between obstetric care that is maximally beneficial and a patient's desire for delivery mode. Clinicians should be aware of the potential implications of this dilemma.

Objectives Hemorrhage risk assessment tools have been studied using estimated blood loss. We study the association between peripartum hemorrhage risk assessment score and peripartum quantified blood loss (QBL) in term vaginal and cesarean deliveries. Methods This is a retrospective analysis conducted on 3,657 patients who underwent term vaginal and cesarean deliveries at a public hospital in New York City. Utilizing the risk assessment tool developed by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), patients were categorized into low-, medium-, or high-risk groups for postpartum hemorrhage. Results Medium-risk (B=0.08, SE=0.01, p<0.001) and high-risk (B=0.12, SE=0.02, p<0.001) AWHONN scores were associated with significantly higher QBL as compared to low-risk AWHONN score. Medium-risk approached significance (OR: 1.67, 95 % CI: 1.00, 2.79, p=0.050) and high-risk AWHONN score was significantly associated (OR: 1.95, 95 % CI: 1.09, 3.48, p=0.02) with increased odds for postpartum hemorrhage (>= 1,000 mL). Each individual factor comprising the AWHONN score whose percentage in our sample was seen in greater than 2.7 % of patients was independently significantly associated with increased QBL (six of nine factors) and postpartum hemorrhage (four of nine factors). Conclusions The AWHONN measure previously validated with estimated blood loss predicted obstetric blood loss with QBL. Although not on the basis of the data shown in our study, we believe that QBL should be routinely used to measure obstetric blood loss.

Objective To evaluate whether prenatal visits or screening/testing were fewer or occurred later during the initial phase of the COVID-19 pandemic in 2020 (CINT) as compared to the prior year (PreCINT). Methods A retrospective cohort study compared CINT ( n = 2,195) to PreCINT ( n = 2,395) at seven public hospitals in New York City. The primary outcome was total number of prenatal-care visits. Secondary outcomes were components of prenatal-care visits completion, timing of standard pregnancy screening tests, and adverse neonatal outcomes. Results CINT patients had more total prenatal-care visits (B = 1.30, 95% CI:1.04, 1.56, p < 0.001), lower odds for initiation of prenatal care which was inadequate according to widely used criteria (OR:0.39, 95% CI:0.34, 0.45, p < 0.001), and lower gestational age at initial visit (B=-4.51, 95% CI:-5.10, -3.93, p < 0.001) than PreCINT patients. In-person visits did not differ between the two groups. PreCINT patients had no televisits, while CINT patients had a median of one televisit (Median = 1, p < 0.001). CINT patients had increased odds for group B Streptococcus screening (OR:1.27, 95% CI: 1.10, 1.48, p = 0.001), quadrivalent screening (OR:1.30, 95% CI:1.15, 1.48, p < 0.001), and anatomy sonogram (OR:2.30, 95% CI:2.04, 2.59, p < 0.001) but decreased odds for glucose challenge test screening (OR:0.81, 95% CI:0.72, 0.91, p < 0.001). Adverse neonatal outcome did not differ between CINT and PreCINT pregnancies. Conclusions for Practice Despite the difficulties and perceived dangers of in-person visits during the COVID-19 pandemic, the COVID-19 pandemic had little negative impact upon the outpatient prenatal care received by patients in this hospital system.

INTRODUCTION:Assessing intentions, attitudes, and knowledge about breastfeeding among different language groups is important because the languages reflect cultural differences. We compared attitudes, subjective norms, perceived behavioural control, intentions, and knowledge of breastfeeding among mothers with the five most common preferred languages spoken at a New York City hospital.MATERIALS AND METHODS:This cross-sectional study surveyed women (n = 448) in the prenatal clinic and the post-partum unit of a New York City hospital. The survey questions were about breastfeeding attitudes, subjective norms, perceived behavioural control, and intentions, based on the Theory of Planned Behavior. We also administered the Iowa Infant Feeding and Attitude Scale and measured the knowledge of the mothers about breastfeeding. The preferred language spoken by the mother was the main predictor variable. English, Russian, Spanish, Urdu, and Uzbek were the languages studied.RESULTS:Multivariate linear regression analyses showed that Russian (B = 2.24, SE = 1.09, p = 0.04), Urdu (B = 2.90, SE = 1.45, p = 0.046), and Uzbek (B = 4.21, SE = 1.35, p = 0.002) speakers all had significantly more positive attitudes toward breastfeeding than did English speakers. Spanish and English language speakers did not differ from each other in their attitudes towards breastfeeding. The language groups did not differ significantly for subjective norms, perceived behavioural control, intention to breastfeed, the Iowa Infant Feeding and Attitude Scale, nor in knowledge regarding breastfeeding.CONCLUSIONS:Urdu, Uzbek, and Russian speakers had significantly more positive attitudes towards breastfeeding than did English speakers. To the extent that preferred language is a proxy for culture, clinicians can use this parameter as a basis for directing approaches toward lactation education.

Circumcision:Ordinary and Universal in My Community Allan J. Jacobs My1 circumcision experiences are remarkable mostly for their ordinariness. My wife Danaë gave birth to our son Perseus2 while I was a resident in obstetrics and gynecology in a city where we had no family. Perseus was circumcised in a Jewish brit milah3 ceremony on the eighth day of his life, as were my wife's and my male ancestors back into ancient times. We were relieved because Perseus had just recovered from a potentially serious condition. After a difficult forceps delivery, his blood bilirubin rose almost to the point where he might have developed the dreaded kernicterus syndrome. Kernicterus can cause permanent severe motor, intellectual and visual impairment. It was unclear whether he would be discharged from the hospital in time. He had to spend a week in restraints under a bright light whose frequency degraded bilirubin. Happily, he came home the day before the scheduled brit. Our four parents attended the brit. Danaë's father was the sandek,4 being granted the honor of holding our son on his lap during the circumcision ceremony. The mohel, or circumciser, was the local Conservative rabbi. We were mildly anxious because he didn't do many circumcisions in this city with few Jews. Perseus cried briefly after he was circumcised. The circumcision undoubtedly was far less stressful than treatment of elevated bilirubin. The circumcision certainly was less painful than the prodding and sticks for the many blood tests he had to undergo in the hospital, not to mention the pain of his difficult forceps delivery. Perseus did not seem to have much discomfort in his penis afterward, and had no circumcision complications. After the brit, our parents and my resident colleagues ate refreshments and chatted for an hour or so. A brit milah is a happy occasion, but not an elaborate one. It marks the end of the joy, anxiety, and excitement of the child's birth and its aftermath and is followed by the less exalted rhythm of feedings, diaper changes, and sleep deprivation. At the brit, our boys are assigned Hebrew names and confirmed in the Biblical covenant between God and the Hebrew people established between God and Abraham, and reaffirmed between God and Moses. Regardless of the historical truth of the formation of the covenant, it is accepted as a myth tantamount to [End Page 71] truth. In other words, regardless of its literal truth, such a myth is to be regarded as true because it concretizes God's demands or a moral truth. The covenant is real for me whether or not there was a historical Abraham. As with other religious commitments, the obligation to circumcise our sons is unprovable, but binding. On this basis, Perseus's ancestors on both sides were circumcised in brit milah ceremonies for many centuries into the past. My two grandsons were circumcised as well. Achilles was circumcised among friends and relatives. The mohel was an experienced obstetrician who was certified to officiate at a brit milah following the practices of Conservative Judaism. He administered adequate analgesia with topical local anesthetic cream followed by an injected regional block. Achilles slept through his circumcision, suffered no complications, and had little discomfort afterward. My other grandson had a circumcision performed as an infant outside the context of Judaism and is not being raised as a Jew. The two brit milah in my family were beautiful, dignified ceremonies, welcoming the infants into the Jewish fold, and bestowing their Hebrew names.5 Some of my relatives, including Perseus's son, had circumcisions performed in a medical setting without a ceremony. None of the many boys in my family had obvious short- or long-term problems with their circumcisions. My social circle has many Reform and Conservative Jews. I have never heard any Jewish man in my circle of acquaintances complain about his circumcision. Circumcision is a given. Problems are rare, and an exposed glans is the norm. Our men typically enjoy sex and have no difficulty in fathering children. Circumcision is part of the comforting cocoon of custom and tribe that helps to protect us as a group. It also reinforces Jewish endogamy...

Procedural safety is one of the determinants of whether parents ought to be able to authorise ritual circumcision (foreskin removal) for their minor children. The penis and clitoris differ greatly in anatomy. Their homology is irrelevant to whether boys and girls should be treated differently regarding circumcision. The infantile male foreskin is easily separable from the penile head for safe removal. It is large enough that circumcision is technically easy but small enough not to be highly vascularised. In contrast, the prepubertal clitoris is tightly bound to the clitoral hood, and both are tightly bound to adjacent non-clitoral tissue. This, and the tiny size of the clitoris, make infantile circumcision dangerous. Circumcision increases in safety with age in girls, for whom the procedure is probably safest after sexual maturation. The opposite is true in boys. Circumcision is safest in infancy but becomes more dangerous as the penis enlarges and its blood supply increases. I argue that religion has sufficiently powerful positive effects within a society, and is sufficiently important to its adherents, as to warrant some deference by the state. In a liberal society, rituals should be prohibited only if likely to create serious physical and psychological harm. Male infant circumcision fails to meet this bar; however, it is uncertain whether this is the case for prepubertal female circumcision.

Objectives: To compare overall survival (OS) in women with endometrial cancer who received hysterectomies with and without oophorectomies. Methods: Data were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) Research Plus dataset. The sample included endometrial cancer women aged 18 and above diagnosed between 2014 to 2018 (n=52,680) who had hysterectomies with oophorectomies (ovary removed) and without oophorectomies (ovary retained). Histology of endometrial cancer included low-grade and high-grade endometrioid carcinoma, papillary serous carcinoma, clear cell carcinoma, carcinosarcoma, and mixed type. Kaplan-Meier curves, log-rank comparisons, and Cox regression analyses were used to evaluate OS. Results: There were 97.4% patients (n=51,324) who had oophorectomies while 2.6% (n=1,356) did not. Mean age was 62.7 years; the majority were White (79.6%, n=41,941), stage I (78.8%, n=41,496), and endometrioid type (78.1%, n=41,142). Adjuvant therapies were radiation (28.3%, n=14,893), chemotherapy (22.6%, n=11,930), and combined radiation/chemotherapy (12.5%, n=6,598). There were 5,051 deaths (9.6%) among which 119 deaths (0.2%) were in the ovary retained group while 4,943 deaths (9.4%) were in the ovary removed group. In the whole sample, OS did not differ between the two groups (p=0.14). In those with late-stage endometrial cancer (stages III and IV), there were lower hazards for OS (HR:0.75, 95% CI: 0.58-0.97, p=0.03) in the ovary removed group. In those with early-stage endometrial cancer (stages I and II), the OS did not differ between the two groups (p=0.21). Conclusions: Oophorectomy in late-stage endometrial cancer patients who received hysterectomy was associated with improved OS. However, oophorectomy in early-stage endometrial cancer patients was not associated with improved OS. Fertility-sparing surgery may be considered for those in early-stage endometrial cancer who desire to preserve ovary function. Further studies are needed to confirm when oophorectomy is indicated in endometrial cancer patients with ovarian activity. Objectives: To compare overall survival (OS) in women with endometrial cancer who received hysterectomies with and without oophorectomies. Methods: Data were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) Research Plus dataset. The sample included endometrial cancer women aged 18 and above diagnosed between 2014 to 2018 (n=52,680) who had hysterectomies with oophorectomies (ovary removed) and without oophorectomies (ovary retained). Histology of endometrial cancer included low-grade and high-grade endometrioid carcinoma, papillary serous carcinoma, clear cell carcinoma, carcinosarcoma, and mixed type. Kaplan-Meier curves, log-rank comparisons, and Cox regression analyses were used to evaluate OS. Results: There were 97.4% patients (n=51,324) who had oophorectomies while 2.6% (n=1,356) did not. Mean age was 62.7 years; the majority were White (79.6%, n=41,941), stage I (78.8%, n=41,496), and endometrioid type (78.1%, n=41,142). Adjuvant therapies were radiation (28.3%, n=14,893), chemotherapy (22.6%, n=11,930), and combined radiation/chemotherapy (12.5%, n=6,598). There were 5,051 deaths (9.6%) among which 119 deaths (0.2%) were in the ovary retained group while 4,943 deaths (9.4%) were in the ovary removed group. In the whole sample, OS did not differ between the two groups (p=0.14). In those with late-stage endometrial cancer (stages III and IV), there were lower hazards for OS (HR:0.75, 95% CI: 0.58-0.97, p=0.03) in the ovary removed group. In those with early-stage endometrial cancer (stages I and II), the OS did not differ between the two groups (p=0.21). Conclusions: Oophorectomy in late-stage endometrial cancer patients who received hysterectomy was associated with improved OS. However, oophorectomy in early-stage endometrial cancer patients was not associated with improved OS. Fertility-sparing surgery may be considered for those in early-stage endometrial cancer who desire to preserve ovary function. Further studies are needed to confirm when oophorectomy is indicated in endometrial cancer patients with ovarian activity.

This book provides a multidisciplinary analysis of the potential conflict between a government's duty to protect children and a parent(s)’ right to ...

o Objective: To probe the relationship between socioeconomic variables and cesarean section (CS) by studying indicators of socioeconomic status (SES) previously unexamined in the United States (US). o Design: Retrospective review of government data. o Setting: New York City. o Population or Sample: Women (n=80,506) who gave birth to a live child during 2018. o Methods: Analysis of data from the New York City Department of Health and Mental Hygiene and from the US census. o Main Outcome Measures: Presence of CS. o Results: Multivariate logistic regression analysis showed higher odds for CS for higher median household income [US$54,500-$108,499 (OR:1.14, 95% CI:1.02, 1.28, p=0.03) and US$108,500-$380,499 (OR:1.36, 95% CI:1.14, 1.63, p<0.001)], and percent receiving supplemental nutrition assistance program (OR:1.01, 95% CI 1.002, 1.01, p=0.003). Lower odds for CS occurred for per capita income [US$32,500-$54,499 (OR:0.91, 95% CI:0.86, 0.97, p=0.002), US$54,500-$108,499 (OR:0.79, 95% CI:0.71, 0.88, p<0.001), and US$108,500-$380,499 (OR:0.82, 95% CI:0.71, 0.94, p=0.01)]. No significant association occurred for public assistance. o Conclusions: We recommend from a public health perspective that using neighborhood SES information has the potential to improve health systems to better deliver care. Patient preferences may be related to SES. There may be conflicts between obstetric care that is maximally beneficial and patient’s desire for delivery mode. Clinicians should be aware of the potential implications of this dilemma.

It is not necessary to invoke concepts such as reproductive rights or reproductive justice to address the needs of reproductive health. A modus vivendi based on personal and public health needs and sufficiencies will protect the needs of all in a more parsimonious way, while probably generating less conflict than do controversial assertions of reproductive right and justice. Some controversy is inevitable, as traditional pronatal views clash with an apparent need for more antinatal mores generated by adverse Anthropocene changes resulting from rapid population growth and resource consumption over several centuries. The chapter proposes a body of information that all children need to know to protect their safety. It also suggests that, for public health reasons alone (as suggested by Douglas Diekema), reproductively capable minors should be entitled to private and confidential access to prevention of conception and childbirth on the same basis as adults. The chapter discusses, but does not resolve, whether a parent should be permitted to compel the abortion of a fetus carried by a minor who is incompetent to make decisions. It also discusses the prerogative of a minor to place her child for adoption.

This brief chapter describes concepts that will be used as a basis to explain and justify claims by the state for itself, and for society beyond the family. Public health is a collective good that focuses on disease prevention, is consequentialist in its outlook, and frequently involves use of state power. In a liberal democracy, health must usually be defined relatively narrowly, as prevention of disease, rather than used as a broad concept to justify massive social engineering. Optimizing health is a public good and a common good; it benefits all, and requires the cooperation of all. As such, it requires a degree of societal solidarity that has been notably absent, for example, in the United States during the recent COVID-19 pandemic. Free riding must be minimized. Harm reduction as a means of mitigating harmful behavior is discussed as a public health strategy.

Health care workers or others may wish to override parental decisions because of their impact on the health or safetySafety of a child or others. Justification of such an action requires two types of principle: an authorityAuthority principle that designates the process for reversal, and anPrincipal, intervention intervention principleIntervention principle that specifies the grounds for reversal. It is generally accepted that states may overruleOverrule parentsParents’ decisions for good cause. I argue that the role of the state is to provide sufficient protection against parental malfeasance. Parental malfeasance can be construed as either exposing a child to harmHarm or as insufficient defense of the child’s interestsChild's interests. I propose a test to determine what sorts of parental decisions might trigger intervention. I also propose constraints on government action to minimize government unfairness in applying the test. I show how this plays out in application.

The question of prevention and screening differs from treatment of disease in its greater impact on society. Prevention and early detection of serious illness has major human and financial implications. Motivated in part by observation of widespread lack of social concern during the recent COVID-19 pandemic, I argue that states have broad power to compel screening and preventive measures. Using vaccination as an example, I describe four paradigmatic cases. In one case, the disease (tetanus) is grave, but not communicable or common. In the second (common cold), it is common and communicable but not serious. The third type of disease (polio) is grave and highly communicable. In the fourth case, the state seeks to vaccinate people not at high risk of serious illness to prevent serious disease in another subpopulation. I maintain that the third and fourth sorts of cases warrant compulsory vaccination of children over parents’ wishes. I also argue that compulsory screening is acceptable if the screening procedure itself does not violate the Direct Effects Basis—i.e., is unlikely to cause serious harm. Finally, I explore, without definitive conclusions, the question of children living in environments in which they are taught unhealthy practices.

This chapter addresses phenomena seen in children that represent departure from a gender essentialist viewpoint. This is the idea that normal people can be categorized as male or female, and that social behavior should ordinarily follow from biological sex. Gender essentialism is integral to most traditional religious and philosophical systems, but is now almost excluded from many academic and professional forums. This chapter discusses gender incongruity, and disorders of sexual differentiation, as examples of challenges to the gender essentialist viewpoint.

Rights are relationships in which the rightsholder is categorically entitled to be left alone (prerogative), to demand some kind of good or performance (claim), to be able to change the status of another (power), or to be exempt from others’ powers (immunity). Looked at ethically, rights are difficult to ground. In the real world, assertions of right tend to be based on specifics of relationships and of the type of situation involved. The existence of an ethical right is often controversial, and is unenforceable in any event. The almost infinite panoply of putative ethical rights-relationships must be reduced to legal rights. Legal rights are limited, written, enforceable, and have no justification except the legitimacy of the government that imposes and seeks to enforce them. Ethically-derived rights cannot serve as a theoretical basis for child welfare. Legal approaches generally prioritize children’s beneficent interests over their abstract rights. Among the putative rights that laws tend to deemphasize, at least in the US, is a presumed right to autonomy. Autonomy is a cluster concept that includes independence from others, choice, authenticity, etc. Empirical studies suggest that most people prioritize relationships, security, and (to a point) material well-being over autonomy. This is in contrast to much philosophical speculation. Furthermore, attention to child autonomy is often a pretext for supplanting parental values. Thus, I reject concern for autonomy as a prominent feature in settling parent-state disputes.

Parents and physicians do not always agree on how to care for a child. In such cases, the state may be asked to arbitrate. Alternatively, the state, for reasons of its own, may seek to restrict parental authority over matters pertaining to children’s health and safety. Much work in this area has focused on the primacy of the child in question. Other work has focused on the parent–child dyad. The needs of other stakeholders, and of the state itself, have received inadequate attention. Furthermore, the appropriate limits of state power have not been sufficiently interrogated. Much liberal democratic thought has pointed out the potential for abuse of government power, but much ethical literature has not seriously considered the impact of government intervention into private relationships. In this chapter I begin to outline the problems the book will consider. I try to show that there is no principled way to settle many controversies over parental decisions. My argument is based on the doctrines of value pluralism and liberal pluralism. However, society owes children the opportunity to flourish. The elements of flourishing should be determined empirically to the greatest extent possible, rather than by armchair speculation.

The family is the basic unit of society, and the interests of family members and the family unit are always relevant. Despite much rhetoric, neither parents nor physicians (let alone the state!) have a true fiduciary relationship with children under their care. Parents are responsible for the physical care of their children, and for their education leading them to a status as productive adults. They are responsible for their children’s flourishing. Neither their responsibility to an individual child nor their responsibility to the government is categorical. First, parents appropriately balance the interests of all family members (including their own), and the corporate interests of the family as a whole. Second, the state has non-coercive means of intervention at its disposal. This chapter reviews and expands on some prior approaches to parental authority and responsibility. The chapter classifies parental behavior into four categories, based on the maximum appropriate state response. Parental behavior within the Zone of Acceptability warrants no government attention. The next two zones represent divisions of Gillam’s Zone of Parental Discretion. Parental action within the Zone of State Attention may elicit educational efforts and the provision of services. Parental behavior within the Zone of Concern invites nudges, mandatory programs with op-out possibilities, etc. Finally, parental behavior within the Zone of Unacceptability justifies coercive state action to reverse or punish potential or actual harm. Harm may not involve the child per se, but can involve third parties, as with parental vaccination refusal.

There is good evidence that height is socially and economically beneficial to males. Consider two parents with otherwise healthy sons. One wants to obtain medical treatment to change her son’s ultimate projected height from 150 (4′11′) to 160 cm (5′3″). The other would give similar medication to increase her son’s projected final height from 190 (6′3′) to 200 cm (6′7″). This chapter explores some of the theoretical and practical considerations in (1) using biomedical technology to change a characteristic of a child from socially disfavored to typical; or (2) to change a characteristic from excellent to outstanding (in terms of societal norms). Prospects are poor for changing norms themselves with regard to important features of interpersonal competition such as mating desirability or markers of social dominance. It is necessary to directly confront the question of when (if ever) it should be permissible to change the child’s body, or even the child’s genotype, to allow him to better succeed within his culture. This leads to interesting ways to frame problems that do not necessary lend themselves to definitive recommendations.