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Related Topics
Ethical Dilemmas in PediatricsReview - Ethical Dilemmas in Pediatrics
Cases and Commentaries
by Lorry R. Frankel, Amnon Goldworth, Mary V. Rorty, William A. Silverman (Editors)
Cambridge University Press, 2005
Review by Andrew Brei
Jan 30th 2007 (Volume 11, Issue 5)

Ethical Issues in Pediatrics is a wonderful addition to the body of bioethics literature.  It is a well organized presentation of some of the ethical issues that can arise in the context of pediatric medicine.  The intended audience, claim the editors, includes primary-care providers, physicians, members of ethics committees, medical students and residents, professional philosophers, and lay people.  This is reasonable, though some members of that last group might be turned off by the rather formal, "academic" style.  The format of the book is one of case/commentary.  Clinical accounts written by physicians are paired with commentaries written by bioethicists.  The editors add their own helpful analyses of the ethical issues at play in each case.

The introduction offers a brief history and description of bioethics, as well as an explanation of clinical ethics ("a patient-centered application of biomedical ethics" (p.3)).  It also provides the means for distinguishing between general clinical ethics and pediatric clinical ethics.  I will mention just a few.  In general cases, a relationship exists between patient and physician; in pediatric cases, that relationship includes parents or guardians.  In general cases, patients participate in the decision process regarding treatments; for the most part, that is not so in pediatric cases.  And in general cases, a patient's autonomy is to be recognized and highly respected; in pediatric cases, physicians may have more regard for their patients' welfare than for their autonomy.

The book is divided into four parts, each containing three chapters (each chapter centers on one case).  For brevity's sake, I will highlight one aspect of each part.  But note that by doing so I am not suggesting that the parts I ignore are lacking in interest or strength.

The first part, Therapeutic Misalliances, involves situations in which the ideal relationship between patient, physician, and guardian is not realized.  The ideal relationship, called a therapeutic alliance, is one in which all parties (or, as in many pediatric cases, the physicians and guardians) agree on the goals of treatment and the means by which to achieve them.  The first case in this part details the struggle between a mother and the physicians charged with caring for her infant daughter.  A misalliance was created when the mother insisted that a spiritual advisor's prescription be followed (which called for the infant to ingest an herbal brew and also involved applications of the same herbal brew on the infant's chest in coordination with the full moon).  In the end, the mother and the physicians reached a compromise.  The infant would not ingest the tea but would have it applied to her chest.  The doctors believed that the tea would likely do no harm and might provide some therapy.

Richard B. Miller provides commentary for this case, and I quite like his analysis.  Miller frames his comments with a context of cultural sensitivity.  The idea is that in this age of respect for diversity, it is good for a healthcare system to act in accordance with a patient's cultural or religious views (although such action should be constrained by a patient's best health-related interests).  This brings out an important aspect of pediatric clinical ethics--namely, the fact that it is an intervention into family relationships.  As such, the interests of a patient's family members must sometimes be met.

But Miller also offers an explanation of what it means for physicians to provide adequate care, and on this basis he objects to the way the doctors acted in this case.  Part of what it is to provide adequate care is for physicians to inform parents of possible connections between their habits and their child's health.  Miller calls this the "transformational approach".  What the doctors in this case should have done is to look more carefully at the new age remedies used by the mother to see if they pose a present or future health threat to her child.  This kind of education is part of the treatment that doctors ought to provide.

The second part, Medical Futility, deals with cases involving the maintenance or withdrawal of life-support.  The term 'futile' can be understood in this context as meaning 'medically inadvisable'.  What is to be done when doctors advise against the continuation of life-sustaining treatment and parents/guardians request it?  The second case in this part involves a child who required long-term mechanical ventilation.  Doctors in this case--guided by professional standards, experience, and concerns about resource utilization--advised that such treatment not be pursued.  The child's mother requested that everything possible be done to maintain her child's life, and her wishes were honored.  The doctors noted that the reasons they had for discontinuing treatment were not forceful enough to overcome the mother's desires.

Anita Silvers takes exception to the decision process at work in this case.  She makes the important point that clinical ethics is often guided by casuistry (case-based reasoning) rather than ethics (principle-based reasoning).  Her assessment of the case shows that the doctors arrived at a conclusion dissimilar to their inclinations after failing to properly categorize the case at hand.  They were thus unable to apply an ethical principle.  What they ought to have done, says Silvers, is to attend to the particulars of the case and not to its categorization into one or another ethical paradigm.  This is valuable advice, especially in a bioethics framework and particularly in the context of pediatrics.

The third part, Life By Any Means, focuses on three cases in which complex, invasive, and high-risk interventions are necessary for prolonging life.  One involves heart surgery while the other two involve organ transplantation.  The latter cases raise questions about, among other things, the allocation of organs.  The second case in this part is fascinating because it has to do with the prenatal diagnosis of a heart condition and the inclusion of an unborn person on a transplant candidate list.

Joel Frader does a nice job of keeping distinct the issues of appropriate treatment and appropriate allocation of resources.  He is careful not to draw any conclusions regarding one issue on the basis of the other.  In the case at hand, there is a question about which course of treatment was the right one to prescribe.  Frader's contention is that the scarcity of donor hearts is not enough to recommend alternative treatment in this case, primarily because the data does not yet exist to demonstrate the comparative effectiveness of the alternative (in this case, surgery).  Frader includes a brief discussion of the morality and policies regarding the addition of a fetus to a transplant candidate list.  This is itself a fascinating ethical issue, deserving of its own analysis (in another forum).

The fourth part, Institutional Impediments to Ethical Action, focuses on the problems that can be caused or exacerbated by health-care institutions.  The organization and arrangement of these institutions is getting more and more attention because of the effect they can have on the quality of the medical care these institutions provide.  The second case in this part was written by Joy Penticuff, a nurse educator, and thus provides the reader with a valuable and unique perspective.  Her piece clarifies what she calls "ethics within arm's length", a notion that points to the close proximity in which nurses stand to their patients in order to highlight the special relationship that exists between pediatric nurses and patients.  The case involves the decision--made by the parents of a prematurely-born infant and a hospital ethics committee--to limit the number of attempts nurses would make to restart a failed IV (an IV that provided the infant with her primary sources of nourishment and hydration).  Penticuff laments the lack of nurse-input in this decision, pointing out that nurses rarely share their valuable opinions with hospital ethics boards.

In her commentary, Mary V. Rorty offers a nice analysis of the difference between withdrawing treatment and limiting the number of attempts to administer treatment.  By her reasoning, there is no moral difference (at least in the case at hand).  The decision in this case to limit the number of attempts rather than to simply withdraw treatment probably reflects a psychological reluctance, prevalent in the medical community, to withhold hydration and nutrition from young patients.  No doubt, intuitions and emotions play a part in making decisions such as the one made in this case.  But the main point of Rorty's comments echoes a point made by Penticuff: this case is one in which the nurses ought to have been a part of the decision-making process.  By leaving them out, the parents, physicians, and ethics committee failed to respect the nurses as active, caring moral agents.  This insight provides a valuable prescription to all health-care institutions.

Without exception, the cases in this book are well presented and the commentaries are thoughtful and interesting.  The editors of Ethical Issues in Pediatrics are to be congratulated for assembling this collection of works which highlight so well some of the key issues in pediatric clinical ethics.



© 2007 Andrew Brei


Andrew Brei is working on a dissertation entitled "Our Right to Health and Our Duty to Nature," and expects to receive his Ph.D. in philosophy in 2007.  In the meantime, he teaches ethics at Purdue University.


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