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Attard-Montalto S*. Ethical Issues in Paediatric
Practice - Part I: General Principles. Images Paediatr Cardiol 2002;9:1-3
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*
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Chairman, Dept. of Paediatrics, St. Luke’s Hospital,
Malta
Academic Head, Dept. of Paediatrics, University of Malta Medical School |
| Ethics |
Article
Introduction
Clinical problems with significant ethical implications pose an ever
increasing dilemma in everyday medical practice in the 21st century and
rarely present a simple solution. This is particularly the case with ethical
issues involving children and those unable to take their own decisions.
Whilst the patients’ interests should come first and all personal, cultural
and religious bias eliminated, the impact of costly treatment for the individual
patient on the available healthcare resources must also be taken into account.
Hence it is essential to establish an ethically acceptable code of practice
which will allow doctors to provide an objective approach to management
that is both rational and consistent, both for the child as well as society
at large regardless of creed or culture. In this editorial we shall review
some of the general principles that guide medical ethical problems, whilst
the forthcoming series of articles will address specific ethical issues
relating to disability, the initiation of intensive care or ‘extraordinary’
measures and, finally, issues relating to the discontinuation of care and
the dying process.
General ethical principles
The ideal code of ethically acceptable practice may be approached,
if not fully achieved, by applying the following accepted principles in
the decision-making process.
1. Respect of the individual’s autonomy
Autonomy implies that all are free to take an active and totally independent
role in the decision-making process. For this to occur, patients must be
fully informed and understand the implications of their medical condition,
its treatment, complications and outcome. In practice, however, the vast
majority of children do not have the ability to be truly informed, and
rely on others for guidance. If anything, this situation heightens the
doctors’ responsibility to ensure true informed consent, albeit through
third parties.
2. Respect of the individual’s competence
Competence implies the patient’s level of understanding that allows
him or her to weigh up the ethical issues posed by a clinical situation,
assimilate these and reach a rational decision. This degree of comprehension
is often a problem with young children, thereby increasing the responsibility
of parents and the medical team to assume the role of competent advocates
on their behalf.
3. Respect beneficence
Beneficence defines the medical principle of ‘do no harm’, a hallmark
of the Hippocratic oath, and should apply in all cases. Medical practice
frequently entails a compromise between benefit and harm, especially with
regard to interventional procedures and drug therapy, but should always
be biased toward ‘benefit’. Hence, in practice, it may be perfectly acceptable
to embark on high-risk therapy in a fully informed individual (or his/her
advocate), provided there is a realistic chance of reasonable benefit.
4. Respect of the truth
There is never a case for wilfully lying to patients. Similarly, there
is rarely any justification in withholding or omitting information from
patients.
5. Respect of patient confidentiality
All patients have a right to confidentiality. However, disclosure of
confidential information without consent may be justified in situations
where failure to report may lead to greater disadvantage to the patient
(e.g. physical abuse).
6. Avoidance of paternalism and bias
Practitioners should strive to remain truly objective and avoid all
personal, racial, cultural, religious or other bias when counselling or
treating children. Personal prejudice and preconceived ideas must never
influence the provision or withholding of medical care to patients, regardless
of whether they are disadvantaged, have a pre-existing disability or otherwise.
The wishes of parents and guardians must also be respected, again regardless
of any personal bias.
7. Avoidance of all conflicts of interest
The patient must always come first, before any vested interest of any
third party including physicians as well as the parents, guardians, extended
family and society.
8. Respect the limitations of medical care
Medical care should strive to support the patient, and should be tailored
to the needs of the individual including any complications or disabilities.
It is ethically appropriate to appreciate realistic goals which medical
care can achieve, and wrong to aim toward exaggerated or impossible expectations.
Hence, it is equally unacceptable to ‘treat at all costs’, as it is to
‘play god’.
Ethics in the decision-making process
Given the above accepted guidelines, ethically acceptable decisions
can only be based on
| Omniscience | knowledge of all the facts |
| Omni percipience | consideration for all the points of view |
| Disinterest | absence of any vested interest in the various parties |
| Dispassion | avoidance of any emotional bias |
| Consistency | management that is reproducible for all similar cases |
Informed consent
Informed consent is not necessary simply to satisfy medicolegal requirements,
but is indeed a pivotal issue with regard to patients’ ‘free choice’ and
active participation in their own management. It is fraught with problems
in the competent adult, and is doubly more difficult to achieve in minors.
Truly informed consent can only exist when patients are sufficiently informed
to weigh up all the pros and cons of treatment, and their consent is given
freely without coercion, vested interest or bias from physicians or third
parties.
Conclusion
Medicine is never a pure science and contentious issues in management
abound. A single, simple solution to a given ethical problem in medicine
is extremely unlikely, particularly in patients who are either too young
or incapable of grasping the nuances of treatment. These patients rely
on third parties for their decision making, and this adds a further dimension
to an already complex situation. It is only by careful attention to a strict
code of ethics based upon respect and tolerance of other persons, whether
‘competent’ or not, that decisions can be taken which are truly in the
best interest of patients and society at large.
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