Pediatrics: Ethics

Question 1

Rights-based dialogue of ethics in peds palliative

Answer 1

Provides a legalistic account of how a clinician should treat a child, assigns human rights to all individuals and does not differentiate between adults or children.

Notable as children are often considered ‘works in progress’ rather than current ‘persons’.

Question 2

Four principles of ethics, particularly in context of peds palliative

Answer 2

Autonomy - Own capacity to decide what medical treatment is done (difficult in relation to children)

Beneficence - Responsibility of the clinician to do what is good for their patient (difficult to distinguish between interests of children and families)

Non-maleficence - Duty of the clinician to avoid harm (difficult to distinguish between interests of children and families)

Justice - The responsibility of clinicians to participate in designing and maintaining a healthcare system that is fair

Principles are often in conflict - e.g. autonomy (preference for resusitation of a very preterm infant, for example) can be at odds with non-maleficence (likelihood of disability) and justice (would consume resources in a world of finite resources)

Question 3

Ethics in Peds Palliative Care: Personhood and rationality

Answer 3

• Personhood often thought to be a function of rationality
• Can argue that there are more ways to reason than only an adult does, but it has been used as an argument to support infanticide.
• However, the moral status of children who are non-rational (ie. severe cognitive impairment) are challenging from an ethical perspective

Question 4

Dependence and Autonomy: Pediatric considerations

Answer 4

Autonomy describes the freedom to decide for oneself

Children’s autonomy can be understood as manifesting by allowing parents to make decisions on their behalf and participating in a reciprocal and balanced relationship with family members.

Cognitive impairment/physical impairment may complicated autonomy, as can parental autonomy. Must disentangle what parents feel their child would want from what parents want.

Question 5

Euthanasia in pediatric palliative

Answer 5

• Adolescents may appear more autonomous than they are
• High levels of risk taking and suicide during adolescence suggest that there are many influences that could play into such a decision
• It may be difficult, in practice, to distinguish between an adolescent’s request for MAiD and a request for more attention or prostest against parental restrictions

Question 6

Concept of ‘best interests’ in peds palliative

Answer 6

• A child’s moral deliberations occurs within the extremely influential space of the family
• May be difficult for a child to articulate disagreement with family
• In children with cognitive impairment, there is no objective measure of what constitutes a good outcome and this complicates how we cater to best interests of the child. In practice, ‘best interests’ in this scenario often ends up being conflated with the parents’.

Question 7

Relationality in ethics

Answer 7

• Applies to concept of justice - ethically right decision depends on the impact/relation with the entire community, not just the individual patient.
• Relationship of physician to child or patient is of ethical importance and the basis must be that all patients are equally important, but those other patients cannot be brought into conversation (e.g. using resource allocation as a justification to deny treatment)
• Ethically relevant decisions need to be made in both relationships - for the individual patients and for the system

Question 8

A 3 year old boy with advanced metabolic degenerative condition was now felt to be in an almost ‘permanent vegetative state.’ Develops pna after a series of chest infections, parents bring him to ED with another infection and insist he should be ventilated again. ICU doc explains that ventilation would not be offered because it would mean their son occupying a bed that another child could use more effectively.

Issues?

Answer 8

• Cruel and unreasonable to expect parents to sacrifice their child for the wellbeing of others.
• Emphasises the tension between justice and beneficence - physicians must make ethically sound decisions for ‘other children’ but also for the child in front of them
• However, ‘other children’ are outside of the scope of the patient-doctor relationship in this particular instance and needs to be reflected in the conversation.
• Is it worth arguing that it is cruel and unreasonable to ventilate a child when it may simply contribute to suffering rather than benefit?

Question 9

Consequentialism in ethics

Answer 9

Argument that the only morally relevant aspect of an action is found in its outcome (ie. the outcome of an ethical decision can be worse by obeying a rule than by breaking it).

The outcome may be “the sum total of human happiness”, but is difficult to measure and weight.

Question 10

Deontological ethics

Answer 10

There is an absolute morality that is equally relevant to all people, in all situations, irrespective of the consequences

E.g. God through religious scripture

Question 11

Virtue ethics

Answer 11

Concept that an action is right if it is done by a virtuous person for the right reason. (e.g, as laid out by the Hippocratic oath).

May govern and shape the expectation of professional behaviour, but may not replace the analytical approach needed to clinical ethics

Question 12

Principle of double effect

Answer 12

An acknowledgement that the clinician can foresee a range of outcomes from a single act, but only intend a subset of them. (e.g. giving morphine to ease pain at end of life - it could depress respiration or cause anaphylaxis and hasten death, but the intent is for relief of suffering and so is just).

Note that it is not a blanket allowance for any action. Proportionality must be shown between the act and its outcome to judge the intention. E.g. cannot give extremely high doses of morphine that cause respiratory arrest and justify by saying the intent was pain control, as that is not congruent if when dose is disproportionate to the degree of pain.

Question 13

Situations in which medical treatment aimed at sustaining or saving lives may be held, as per RC of Peds and Child Health in the UK:

Answer 13

1. Brain dead or permanent vegetative state - child no longer has interests and the residual interests are those of others. Beneficence no longer applies to child, but rather the family’s interests.
2. No chance situation - The “no chance” category covers the child for whom life-sustaining treatment will merely delay death, without significantly relieving the suffering caused by the disease. In this case the child’s best interests are served by not prolonging treatment
3. Unbearable situation - Inherently subjective and requires intensive work with caregivers and the child to determine what is and is not unbearable.
4. No purpose situation - refers to when a child’s life may be saved by medical treatment, but the degree of mental or physical impairment may be so great that the quality of life for the child is intolerable.