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Anesthesiologists should choose to involve children in medical decision-making with the ethical objective of enhancing the child's self-determination, while keeping the child engaged in their care. Anesthesiologists can use the patient's age as a first approximation of a patient's cognitive and emotional development. This chapter discusses the issues raised by incorporating the ethical concept of pediatric patient assent into the traditional process of parental (surrogate) informed consent. Competency is a legal term while decision-making capacity is the ability to make a specific decision at a specific time. It is important to resolve disagreements among the pediatric patient-parent-physician triad about the appropriate clinical plan. Response to requests for nondisclosure by parents must weigh the goal of the best Znterests of the patient. Emancipated minor and mature minor status pose distinct ethical and practical issues. Confidentiality must be honored, and failure to do so may be harmful to the patient.