Ethics Cases, Instructions for the Essay, and Additional Resources in Pediatric Bioethics
Introduction:
At times during the practice of Pediatrics, clinicians must make difficult ethical and moral decisions to serve the best interest of their patients. The scenarios described below are real cases, address ethical issues unique to pediatric patients and give students the chance to develop practical approaches to these problems. A model case has been included as a rough guide for the amount of detail you should include when analyzing the ethics cases. Please note that you can also find the cases, model case and references on our website: http://depts.washington.edu/peds/students We have also included a list of online resources to assist you with your essay, and to introduce you to broader resources available in pediatric bioethics.
Assignment:
You will turn in a written discussion of one of the following 3 (three) ethics cases by 5PM on the third Thursday of your rotation. Please submit essays to the Medical Student Coordinator by email or hardcopy. Your essay will be evaluated and returned to you with comments by the end of your rotation. An evaluation sheet is included at the end of this handout with a summary of the criteria we will use to evaluate your response.
Goals:
The major goals of this exercise are:
To identify the professional obligations in each case: medical, ethical and social
To formulate exactly what your arguments/interventions would be in the cases
To identify how your actions are justified by supporting your arguments/interventions with the basic ethical principles.
In your write up you should:
- Identify the ethical issues raised by the case;
- Explain how you would weigh the various sides of the conflict(s)/view the different arguments;
- Develop a plan to resolve the problem and the ethical conflicts;
- Understand which basic ethical principles guided your plan.
Group Discussion:
There will be a group discussion of the cases during one of your inpatient Thursday morning lectures. Be prepared to discuss the following for each case, as everyone is expected to participate: The ethical issues raised by each case; How you would weigh the various sides of the conflicts/view the different arguments; How you would develop a plan to resolve the problem and the ethical conflicts; Which basic ethical principles would guide your plans.
Ethics Cases
Case 1:
A 15-year-old boy with inflammatory bowel disease (ulcerative colitis) is hospitalized for severe abdominal pain. He has been hospitalized multiple times for antibiotics, bowel rest and intravenous nutritional therapy. His parents have read about surgical interventions that may help. He adamantly states he doesn’t want any surgery.
Case 2:
You are a primary care physician who is assuming the care of a family. Upon review of the past medical history of the 1-year-old daughter, you find that she has no immunizations although she received several well child examinations with their chiropractic caregiver. Her current medications include Chinese herbal supplements and the family follows a vegan diet. You ask the parents why your patient hasn’t received immunizations and they state, "We don’t believe in immunizations".
Case 3:
You may also write about a case that you have seen or heard about that relates to a core issue in pediatric ethics. Please try to link the case to the Ethics Benchmarks as these represent the core content you should be familiar with by the end of your rotation.
http://depts.washington.edu/peds/students/core_materials/ethics_probenchmarks.html
Parental rights to guide care
Child Abuse reporting
Care of Adolescent Patients
Decision-making capacity
Emancipated Minor, Mature Minor status
Confidentiality
Informed Consent, Parental Permission, Child Assent
Admitting Mistakes
Learning Issues
*Again, please come prepared to discuss all cases, not merely the case you have written-up.
Resources in Pediatric Bioethics
Most of the questions posed by these cases are addressed in the following resources:
University of Washington School of Medicine
(1) Pediatric Clerkship UW
http://depts.washington.edu/bioethx/topics/index.html
This website presents core materials about ethics and professionalism for each clerkship at UW. Go to the pediatric clerkship section for specific information. Benchmarks for Ethics/Professionalism for Pediatric Clerkship (see “Additional Information” section of this manual, or: http://depts.washington.edu/peds/students/core_materials/ethics_probenchmarks.html
(2) Treuman Katz Center for Pediatric Bioethics
http://bioethics.seattlechildrens.org/education/education.asp
The Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital and the University of Washington offers a number of helpful resources for pediatric bioethics. You may also access past conferences and videos of the presentations. Check the calendar for grand rounds presentations on ethics, guest speakers, and other educational activities.
National Resources in Pediatric Bioethics:
(3) American Academy of Pediatrics
http://www.aap.org/sections/bioethics/default.cfm
American Academy of Pediatrics has been at the forefront of ethical policy development for the Pediatrics profession. While AAP policy statements are not legally binding, they reflect the considered wisdom and consensus of leadership in the profession. The ethics policy statements and full length articles from the membership are some of the most thoughtful ethical discussions among professional statements in medicine. The site is also the best place to go to see a comprehensive list of both classic and current articles on issues in pediatric ethics. Click on “current articles”, “classic articles”, and “policy statements” to access these documents.
(4) American Medical Association’s “Virtual Mentor”
http://virtualmentor.ama-assn.org/
Virtual Mentor is a terrific resource sponsored by the AMA. It offers case scenarios, brief discussions and helpful presentations. Enter: “child” as the search word to bring up additional discussions in pediatric ethics:
http://virtualmentor.ama-assn.org/2007/11/ccas3-0711.html
http://virtualmentor.ama-assn.org/2007/08/ccas2-0708.html
http://virtualmentor.ama-assn.org/2007/06/ccas2-0706.html
Classic Textbooks on Ethical Reasoning and Pediatrics:
Jonsen, AR, Siegler, M and WJ Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Ed. McGraw-Hill, San Francisco, 1998.
General Pediatric Textbook (Nelson’s, Rudolph’s etc.): Ethics in pediatric medicine (usually at least one chapter).
Beauchamp TL and Childress JF, Principles of Biomedical Ethics: Fifth Edition, Oxford University Press, 2001.
Lainie Friedman Ross, Children, Families, and Health Care Decision-Making, Oxford, 1998.
Model Case:
The parents of a 4-month-old child with bacterial meningitis refuse admission to the hospital for intravenous antibiotics. They plan to go home and pray with their congregation for the child’s health.
This case illustrates two major ethical dilemmas including: 1) religious/cultural differences between parents and physician; and 2) the right of the parents to guide the medical therapy of children. The other major element that is important in this case is providing adequate informed consent to parents.
It is generally accepted that parents who are competent (in the legal sense) have the responsibility for the well-being of their children, but parental discretion is not absolute. It is usually accepted that the best interests of the child sets the limits of parental decision making. Thus, parents have the right to direct the medical care of their children, as long as their actions do not pose a serious risk to the life and health of the child. It is also recognized that society as a whole (and the physician) has an interest in the welfare of children. Therefore, the medical indications for instituting therapy or with drawing therapy help determine some of the limits of parental decision-making. In this case, the medical and scientific evidence supporting the benefits of antibiotic therapy is clear and the results of with holding antibiotic therapy would result in harm (possibly death) to the child.
Religious freedom and tolerance for other cultures form the basis of our society, and respect for cultural and religious diversity is a highly valued trait. However, while respect for the beliefs of others may form a basis for a productive physician-patient relationship and ultimately serve the best interests of the child, at times the specific beliefs of the parents may harm the child. Again, the value of parents exercising their right to religious and cultural freedom must be weighed again the best interest of the child. "Parents are free to make martyrs of themselves, they are not free to make martyrs of their children" (Prince v Massachusetts, 1944). However, physicians must be wary when limiting parental rights because of differences in cultural/religious beliefs. Not all medical practices are firmly supported by scientific data. Physician bias as well as specific medical practices must be considered when weighing the next course of action.
Finally, one of the major responsibilities of the physician is illustrated in this case—the importance of informed consent. When making therapeutic recommendations to patients and parents, the physician has the responsibility to 1) explain the nature of the intervention, 2) explain the risks and benefits of the therapy proposed, 3) explain the risks and benefits of alternative therapies, including no therapy 4) answer any questions the patient/parent may have and 5) gauge the understanding of the consenting parties. The physician should then give a professional opinion about the alternatives and make a recommendation based on the best clinical judgment. The physician must also make reasonable efforts to insure comprehension by the consenting parties. This case illustrates the importance of careful discussion of each of the elements of the etiology, prognosis and therapeutic options for the child. Such a discussion may reveal specific concerns, misunderstandings or beliefs that can be addressed, thus reaching a mutually acceptable solution to the problem.
In this case, I would listen to the reasons the parents give for refusing therapy. I would then carefully explain the pathogenesis of the child’s illness, the expected outcomes with and without therapy and the possible long term sequelae should the child survive either with or without therapy. I would clearly state that I respect their rights as parents to guide most medical decisions and reaffirm their motivation is to care for their child. However, after confirming that they understand the nature of the illness and the outcome with and without therapy, I would tell them that I am also obligated to provide the best possible care for their child, in this case antibiotics in the hospital. I would explain that I will have to override their decision and admit the child for antibiotics, using a court order if necessary. I would also explain that this is not an arbitrary decision, but based on unequivocal scientific data. I would attempt to deliver this message in an unbiased manner and strongly encourage them to continue to add all other methods of healing they see as appropriate.
By pursuing this plan of action, I would affirm my commitment to respecting cultural differences, serve the patient’s best interests-both medically and socially, by maintaining open communication with the parents and attempt to foster an appropriate physician-patient relationship by adequately informing the parents about all the treatment options. The ethical principles of beneficence, respect for autonomy and nonmaleficence guide these actions.
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