Pediatric Ethics Flashcards
Rights-based dialogue of ethics in peds palliative
- Provides a legalistic account of how a clinician should treat a child
- assigns human rights to all individuals
- does not differentiate between adults and children
- Notable: child considered “works in progress” rather than current persons
- Developmental nature means they are cared for in a family; society’s respon
Four principles of ethics - peds palliative
- Autonomy
- capacity to decide medical treatment on your own
- difficult in pediatrics
- Benificence
- responsibility of clinician to do what is good for their patient
- difficult to distinguish between interests of patients and families
- Non malieficence
- Duty of clinican to avoid harm
- Difficult to distinguish between interests of children and families
- Justice
- Responsibility of clinician to design and maintain a system that is fair
- complicated by fact that society is composed mostly of adults
Principles often in conflict : autonomy can be at odds with non maleficence and justice.
Case: 25 week preterm infant born and conflict around resuscitation. Autonomy: parents wish child to be resuscitated, benficence - resuscitation will help the infact, justice - consumes resources in world of finite resources, non-maleficence - should not be resuscitated because will have disability.
Ethics in peds : Personhood and rationality
- personhood function of rationality
- moral status of children who are non-rationale (severe cog impairment) are challenging from ethical perspective.
Dependence and Autonomy : peds considerations
- Autonomy is the freedom to decide for oneself
- children’s autonomy : allowing parents to make decisions on their behlaf and participating in reciprocal and balanced relationship with family members
- Cognitive impairment / physical impairment complicates autonomy
- Must disentangle what parents feel their child would want from what parents want.
Euthanasia in peds palliative setting
- Adolescents may appear more autonomous than they actually are
- high levels risk taking (suicide, etc) in adolescence
- may influences play into request for MAID
- may be difficult to differentiate between true request for MAID and attention seeking or protest against parental restrictions
Concept of best interests in peds palliative
- Child’s moral deliberations in context of family
- may be difficult for child to disagree with family
- cognitive impairment - no objective measure of what constitutes a good outcome.
- “best interests’ often conflated with parental interests.
Relationality in ethics
- applies to justice
- ethically right decision depands on impact on community, not just individual
- relationship of physician to child of ethical importance
- all patients treated equally
- cannot use resource allocation as justification for denying treatment
- ethically relevant decisions need to be made in both relationships - for indiviudals and for the system
Case : 3 year old boy with advanced metabolic condition felt to be in permanent vegetative state. Develops PNA recurrent, comes inot hospital. Parents insist on ventilation again. ICU MD explains that ventilation would not be offered because it would mean their son would occupy a bed that could be used more effectively.
Ethical issues?
- cruel and unreasonable to expect parents to sacrifice their child for the wellbeing of others
- tension between justice and beneficence and autonomy
- physician must make decisions for other children, but also the child in front of them
- “Other children” are outside the scope of this patient-MD relationship
- Non malificence of ventilation
Consequentialism in ethics
- Argument that only relevant measure of morality is the outcome
- “the sum total of human happiness” is the outcome, but impossible to measure for it for individuals
- in medicine, cannot know the outcome so consequentialism does not provide us with ethical framwork for decision making
Deontological ethics
- Absolute morality equally relevant to all people in all situations, irrespective of consequences
- Sources of moral code:
- Authority of God
- Universe itself
- Pure reason
Virtue ethics
- concept that an action is right if done by a virtuous person for the right reason
- may govern and shape professional behaviour, but may not replace analytical approach for clinical ethics
Principle of double effect
- range of outcomes from a single act
- only intend some of them
- needs to be proportional action to outcome to be just
- Case : 9 year old boy with severe CP extubation and palliative extubation planned for EOL. MD wants to give 2mg/kg oral morphone as single IV bolus during extubation.
- Three possible outcomes: analgesia, anaphylaxis, apnea
- this dose is disproportionate to perceived analgesic/dyspnea needs
- very probable to cause apnea at this dose, therefore not ethically acceptable
Withholding/withdrawing life sustaining treatment:
RC peds and child health UK
- Brain dead / perm vegetative state
- child no longer has interests.
- interests are of family only
- beneficence does not apply to child, but to parent’s interests
- No chance situation
- life sustain tx will only delay death
- will not relieve suffering caused by disease
- best interests served by not prolonging life
- Unbearable situation
- subjective
- explore with child
- No purpose situation
- child’s life MAY be saved by tx, but degree of mental / physical impairment may be unbearable
- assumes child cannot participate in conversation about unbearability
- Responsibility of carers to make a wise and compassionate decision about what is best for the child (not to give a voice to his/her wishes)
Death should sometimes be allowed to occur
Only indisputable relevant ethical question : whether intervention likely to do more good than harm individual child.
