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DE LA SALLE HEALTH SCIENCES CAMPUS – COLLEGE OF MEDICINE

Detoxicol
SDLS 2008
Medicine for the intoxicated
Subject: Bioethics Lecture Date: December 02, 2005
Topic: Principles and Issues in Pediatrics Transcriber(s): Toxicaceous Necrosis
Lecturer: Dr. Melchor Frias No. of pages: 7

Kids, the portions of the text in italics are the explanations Dr. Frias gave during lecture. The parts in normal or bold font are
from the powerpoint. Be sure you get a copy of the Past E! … Evil. – Kacy 

PRINCIPLES & ISSUES IN PEDIATRICS

OBJECTIVES:
At the end of the session, the student is able to:
• Explain specific Principles related to Pediatrics
• Explain specific Issues related to Pediatrics
• Apply the principles in given Situations involving specific issues
• Judge what is Ethical and/or Unethical as regards to the practice of pediatrics

PRINCIPLES & ISSUES IN PEDIATRICS:


1. RELATING TO PATIENTS
2. MAKING DECISIONS
3. TELLING THE TRUTH
4. TREATING ADOLESCENTS

RELATING TO PEDIATRIC PATIENTS


• most of the time, the doctor has TWO patients: the child, and his/her parents
• In pediatrics, your patients are children & adolescents

DOCTOR-PATIENT RELATIONSHIP

 WHAT IS THE BEST DOCTOR-PATIENT RELATIONSHIP?

THE DOCTOR-PATIENT RELATIONSHIP IS BUILT ON MUTUAL TRUST:


• PARENT’S TRUST IN THE PEDIATRICIAN
o Promotes Honesty & Cooperation
 Get the parents’ trust.
 Are important factors in history taking
 HONESTY
• If the patients do not trust you, they may fail to give you a complete history, or may actively
conceal things from you
 COOPERATION
• Promotes compliance in terms of the recommended treatment for their child
o Promotes Confidence to Accept the Medical Help Their Child Needs
 If the parents have confidence in the pediatrician, they will comply with the treatment
 Situation: It is difficult to get children to comply some treatments, such as taking medications,
because the taste may be bitter. If the parents have confidence in you & are compliant, they will
find ways to get the child to take the medication, like hiding the medicine in his food… etc.
• PEDIATRICIAN’S TRUST IN THE PARENTS
o Promotes a Partnership Between them
 The Parents are an important Treatment Partner of the pediatrician in caring for the child

OBLIGATIONS & LOYALTIES

 WHEN ARE THE PEDIATRICIAN’S OBLIGATIONS TO PARENTS LEGITIMATELY OVERRIDDEN BY OTHER


OBLIGATIONS?
• The pediatrician’s First Loyalty is Always to the Child
• Situations that present clear & imminent serious danger to the child’s life or well-being, whether posed by parents
directly or by conditions that the parents cannot correct, demand that pediatricians put into motion whatever is
required to protect the child.
• IN CASES OF CLEAR & IMMINENT DANGER TO THE CHILD:
 Situation: in cases of Child Abuse or Neglect
o The pediatrician’s First Loyalty is to the Child
o Second Loyalty is to the State
o Third Loyalty is to the Parents
 In this case, you may contest the decision of the parents if it clearly endangers the life of the child
 You may take the matter up with the courts, or with the hospital’s Bioethics Committee
 Principle: BENEFICENCE – Pediatricians should always act to protect the child

• WHEN THERE IS NO CLEAR & IMMINENT DANGER TO THE CHILD:

 Situation: in cases of Acute Respiratory Infections


o First Loyalty is to the Child
o Second Loyalty is to the Parents

MAKING DECISIONS

 WHOSE CHOICE?
ISSUES:
• Parent’s Rights
• Consulting the Child

PARENT’S RIGHTS:

• Do all parents have rights over their children in terms of treatment decisions?
• The Parents Are ALWAYS Recognized as the Decision Makers by the Pediatrician
o This does NOT mean that you can’t contest their decision if you do not agree with them, but find out what
their reasons are first.

WHY WE RECOGNIZE THE PARENTS AS DECISION MAKERS:


• They are the ones charged by society with the responsibility for the welfare & up-bringing of children
• Parents are the people who live most directly with the consequences of their child rearing
o They live with the child all their lives & may know what is in the best interest of the child
o The pediatrician (especially during the first consult) may not be familiar with the family’s values
o For a physician, the “Best Interest of the Child” is always Medical, & the Medical aspect is not always what
is right
o Social & Emotional Issues concerning the child may be addressed by the parents
o Parents who refuse treatment recommended by the pediatrician will have medical, social & financial bases,
and the pediatrician should get to know these bases in order to understand the decision
• They have a genetic tie to their children
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o They are closer to & more intimate with the child
• Parents make the best qualified decision-makers because they know the child best
• The intimacy of family life is among the greatest personal values

EXCEPTIONS: WHAT ARE THE LIMITS OF PARENTS’ RIGHTS?


1. Limits set by Law
• In cases of Child Abuse or Child Neglect
o Naturally, the parents don’t have the best interest of the child at heart
o They will not have the proper decision-making capacity
o Report the case to the government centers
2. Limits set by Society’s Moral Standards
• If the parents are separated
o Both parents must support the child

CONSULTING THE CHILD

• Do children have to be consulted regarding their treatment?


o Answer: YES. Especially if they are older than 7 years old

• Are children competent to make decisions for themselves?


o Children are not fully rational & mature
 Children are not old enough to think rationally & make mature decisions based on rational thought
o Children are not experienced
 They do not have enough experience to make decisions about their future, or they are not yet able
to make considerations regarding their future

• BUT: The evidence about children’s lack of competence can be challenged:


o Decision-making is a Developmental Process
 This means that an older child will be able to make a more rational & mature decision than a
younger child
 The decision of whether or not child will be consulted may depend on the age of the child
 The child can be informed of his illness & the treatment by different strategies (e.g. through play)
o There is some empirical evidence that children generally make the same treatment choices as
adults
 Children with chronic illnesses or fatal illnesses generally make the same decisions as adults with
the same illnesses
o Decision-making is a form of Practical Reasoning. It depends not only on Cognitive Capacities, but
to a large degree on:
 Life experience
 Practice in making Moral judgments
 Using one’s principles
 The patient must be consulted, especially if the he/she is an adolescent
 Adolescents, in particular, must be included in the Decision-Making Process

• Some people are skeptical about the value of consulting children because it is impossible to be sure that it
is voluntary
o The child is almost always in a vulnerable position toward adults

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 A child is always surrounded & challenged by adults, so you cannot be sure whether or not his
decisions are voluntary, or whether he is only doing something under instruction from an adult
o There are psychological pressures from the parents and doctors
 Example: His mother may say “If you don’t take this medicine, we won’t go to Jollibee!”
o For assent to be genuine, there must be the possibility of dissent
 It’s easier to tell if an adolescent is being forced by an adult to assent (more independent)

BENEFITS IN TRYING TO GET CHILD ASSENT:


1. Helps them see the reasons for the medical decisions
o If the treatment & reasons for the treatment are explained to them
o Will foster compliance & cooperation in the child
2. Provides a model of human relationships
o The child has a sense of importance & responsibility
3. Helps train them in decision-making
o The pediatrician contributes to the development of the child as a person
4. Achieves compliance & cooperation
o Most important aspect
o If you explain a procedure to a child and the reasons for the procedure, the child will usually cooperate
(even if it is painful)
 E.g. telling the child what an IV line is & the reason for its use, instead of tying him down & inserting
it right away

• Having a voice in deciding reinforces his sense of himself as a person & helps prepare him for the independent
decision-maker he will someday be.

TELLING THE TRUTH

 WHAT SHOULD I SAY?

• Informing the Parents


• Telling the Child

INFORMING THE PARENTS: Why Tell the Truth?


TWO REASONS THAT ARE RELATED TO THE MORAL & LEGAL REQUIREMENT FOR INFORMED CONSENT:
1. PEDIATRICIAN’S POINT OF VIEW – truth telling is a Protection
• Related to Informed Consent
• Do not insist on the “Doctor Knows Best” stance; always inform the parents regarding the diagnosis
2. PARENT’S POINT OF VIEW – Correct & Full information is a Necessity
• The parents will not be able to make correct decisions about their child if they do not know all the necessary
information

DELAYING OR WITHOLDING THE TRUTH:


• Reasons must stem from concern for the parent or child
o If telling the truth may harm the parents or the child (DOCTOR-PATIENT PRIVILEGE)
• If the information may affect a parent’s decision, then it is Wrong to withhold or delay it

TWO SITUATIONS IN WHICH IT IS JUSTIFIED TO TREAT A CHILD WITHOUT PARENTAL CONSENT OR TO


WITHHOLD THE TRUTH FROM PARENTS:

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1. In an EMERGENCY SITUATION
• Parents may be emotionally distraught over their child’s condition & might not be able to make rational decisions
2. If the Information may do SERIOUS HARM

TELLING THE CHILD

 IS “BENEVOLENT DECEPTION” ABOUT SERIOUS ILLNESS ACCEPTABLE?


• Situation: Telling the child that having an injection won’t hurt, or will just feel like an “ant bite”. (Liars!)

REASONS FOR TELLING THE TRUTH:


1. Will it do more good than harm?
• If the lie does no harm, then Benevolent Deception may be used in the practice of medicine
• Make sure that the lie does more GOOD than harm!
• Situation: Telling the child “If you have this injection now, you’ll get well right away and you’ll never have to go back
to the hospital again!”
2. What is in the child’s best interests?
• Situation: If the child has a life-threatening illness (e.g. Cancer) or a terminal illness
• Benevolent deception may be used in order to spare the child from undergoing emotional stress & making his
illness worse
• Situation: If a child has Terminal Cancer, instead of telling him that he only has 3 more years to live, tell him that he
has another temporary illness, that chemotherapy will make him healthier, etc.

REASONS LYING TO CHILDREN:


1. To protect them, prolong their innocence, get them to do things that will benefit them
• Not telling a child that he has 3 years to live, so that they can enjoy their lives
2. Because one does not trust their judgment
• Almost always present
• However, a large percentage of children with terminal illnesses are aware that they are dying & make the same
treatment choices as adults, with a proper reason to support their decision
3. Because their experience is limited
4. Because their goals are short-term
• However, with proper information regarding the long-term effects of a treatment, they are usually able to think
toward the future & make decisions based on that projection

• Denying children the truth always HARMS them to some degree by slowing their progress toward developing their
own autonomy
• One should decide the balance of benefit to harm

TREATING ADOLESCENTS

 WHEN IS A CHILD AN ADULT?

• Adolescent Age-Specific Values


• Confidentiality

ADOLESCENT AGE-SPECIFIC VALUES

• Values that are held only during the teenage years or given high priority only during that time
• Values that hold little appeal for parents

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• Values which are Temporary
o Conflicts with typically adult judgments of value
o Not “real” Values
• Values that may be retained into adulthood
o E.g. excessive concern for appearance

• Values that should be given serious consideration


o They must be given serious consideration by the pediatrician, because they will influence the patient’s
compliance with the treatment

INCLUDE ISSUES CONCERNING:


1. Body Image
o Example: A teenage girl wants to go to a dermatologist (even if she doesn’t have any skin problems)
because all her friends are.
2. Acceptance by Peers
o Example: A teenager doesn’t want to wear a back brace for her scoliosis because she’s afraid her
classmates will make fun of her.
3. Independence
o Adolescents often go against their parents’ wishes or values just to exert their independence
o E.g. being sexually promiscuous

CONFIDENTIALITY

• The conflict of obligation that the request for confidentiality generates raises interesting questions about the
relationships among 3 parties:
O THE MORAL STATUS OF ADOLESCENT VS. PARENTS
O THE DOCTOR-PARENT RELATIONSHIP
O THE DOCTOR-ADOLESCENT RELATIONSHIP

 Situation A: A 18-year old boy comes to you for treatment with a Chief Complaint of Gonorrhea. It is the third time he has
been admitted. The patient asks you not to tell his parents. What do you do? (choose your own adventure!)
 Situation B: A 14- year old girl comes to you with a Chief Complaint of amennorhea. You give her a pregnancy test (plus
all the other stuff we learned in OB-GYNE) and find out she’s pregnant. She asks you not to tell her parents. What do you
do? (choose your own adventure!)

ADOLESCENT-PARENT RELATIONSHIP

• Do parents have a right to know?


o Parents are the Legal Decision Makers
 Some forms of treatment require Parental Consent
o Parents Provide Financial & Emotional support
 The medications required for treatment may be expensive.
 For Situation B: The patient is going to need her parents’ support during her pregnancy.
o Duty to Society
 In some countries, STDs have to be reported to the government & it is required that parents have
to be informed.
• Parents should nurture the Rational and Autonomous powers of their children
o They should allow their child to make some of his/her own decisions regarding his treatment

DOCTOR-PARENT RELATIONSHIP
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2 BASIC OPTIONS FOR THE PEDIATRICIAN:
1. PARENT’S ALLY – “tell everything” position
o You tell the parents about the boy’s gonorrhea & sexual promiscuity, even if he asks you not to
2. ADOLESCENT’S ALLY
o You treat the boy & don’t inform his parents, even if this is the 3rd time he’s consulted because of
gonorrhea.
3. MIDDLE OF THE ROAD POSITION  This is the ideal position
o Situation A: Tell the patient that if he isn’t more careful with his sexual practices you will have to inform his
parents
o Situation B: Give the patient a deadline / time limit to tell her parents; if she doesn’t comply with the
deadline, you will inform her parents yourself
DOCTOR-ADOLESCENT RELATIONSHIP

• Treatment with or without confidentiality


• HAS 2 REPERCUSSIONS:
o WITHOUT CONFIDENTIALITY:
 Ideally, the parents want whatever is in the best interest of their son/daughter
•This depends on what kind of relationship the adolescent has with his parents
•Find out first what kind of relationship the adolescent has with his/her parent
o WITH CONFIDENTIALITY
 Factors To Consider:
•Seriousness of the medical situation
o Situation A: consider that this is the 3rd time he has come to you with gonorrhea.
Maybe it’s time to tell his parents!
•Maturity of the adolescent
o Assess whether the child is mature enough to take care of himself & make his own
decisions
•Predicted effect on the parent-child relationship
o Make sure that if you do tell the patient’s parents, make sure that:
 The adolescent’s relationship with the parents will not be affected
 Your (the pediatrician’s) relationship with the parents will not be affected

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Sorry kung mahaba yung tranx, 1 hour talaga nag-lecture si Dr. Frias! Favorite topic kasi niya. Anyway, mostly examples lang naman ito. Kung toxic kayo,
basahin niyo nalang yung Past E.
- Kacy

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