What are ethical issues with children?

Images Paediatr Cardiol. 2001 Oct-Dec; 3(4): 1–3.

PMCID: PMC3232508

* Chairman, Dept. of Paediatrics, St. Luke's Hospital, Malta and Academic Head, Dept. of Paediatrics, University of Malta Medical School

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Clinical problems with ethical implications pose an ever increasing dilemma in everyday medical practice, and this is particularly the case with ethical issues involving children and those unable to take their own decisions. In this editorial we shall review some of the general principles that guide medical ethical problems.

MeSH: Ethics

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.

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’.

Given the above accepted guidelines, ethically acceptable decisions can only be based on:

In practice, many of the above ideals do not fully apply to a particular case. For example, it is often difficult to completely separate disinterest and dispassion from patients with whom an attending physician has built a close, professional relationship. For these reasons, it is not just desirable but essential to establish independent ethics committees to oversee particularly difficult decisions (both with regard to clinical medicine and research). These should be composed of medical, nursing, paramedical and legal experts, laypersons and representatives of various support groups.

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.

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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Early childhood educators encounter many ethical issues in the course of their work with children and families. Each of the Focus on Ethics columns in Young Children presents an ethical issue and asks our readers to determine how an early childhood educator might best respond to it.

Is it an ethical issue?

As we have written in NAEYC books about professional ethics, when faced with a challenging situation in the workplace, the first thing an early childhood educator needs to do is to determine whether it is an ethical issue. Our experience tells us that this can be a difficult process, one that many are unsure about. The first question you should ask yourself is, “Does it concern right and wrong, rights and responsibilities, human welfare, or individuals’ best interests?” If you answer no to each of these items, the situation is not an ethical issue and you can handle it as you would handle any workplace concern. If you answer yes to any of the items, you are facing an ethical issue. How you respond to it depends on whether it is an ethical responsibility or an ethical dilemma.

An ethical issue: Is it an ethical responsibility or an ethical dilemma?

Over the years that we have been conducting workshops and teaching courses about professional ethics, we have found that early childhood educators do not always know the difference between an ethical responsibility and an ethical dilemma, nor are they sure about how each should be approached. To make this distinction clearer, we decided to use this March 2016 column to look at these two kinds of ethical issues.

Ethical responsibilities

Ethical responsibilities are mandates that are clearly spelled out in the NAEYC Code of Ethical Conduct—they describe how early childhood educators are required to act and what they must do

and must not do. The fact is, however, that instead of honoring these responsibilities, even well-meaning and conscientious early childhood educators are sometimes tempted to do what is easiest or what will please others. It is important to remember that when you encounter a situation that involves an ethical responsibility, you must follow the Code’s clear direction. The most important of the responsibilities spelled out in the NAEYC Code is Principle 1.1:

P-1.1—Above all, we shall not harm children. We shall not participate in practices that are emotionally damaging, physically harmful, disrespectful, degrading, dangerous, exploitative, or intimidating to children. This principle has precedence over all others in this Code.

You can be confident that when you have done the right thing, the Code is there to back you up. You can rely on it to help you explain why you made a difficult or unpopular decision.

It can be helpful to think of ethical responsibilities as being very similar to legal responsibilities in that they require or forbid a particular action. And sometimes legal and ethical responsibilities are the same—for example, mandating the reporting of child abuse.

Ethical dilemmas

When you determine that a situation involves ethics and you don’t think it is a responsibility, it is likely to be an ethical dilemma. A dilemma is a situation for which there are two possible resolutions, each of which can be justified in moral terms. A dilemma requires a person to choose between two actions, each having some benefits but also having some costs. In a dilemma the legitimate needs and interests of one individual or group must give way to those of another individual or group—hence the commonly used expression "on the horns of a dilemma," describing the two-pronged nature of these situations. The example of an ethical dilemma we often give is the case of the mother who asks a teacher not to let her child nap at school because when he sleeps in the afternoon he has a hard time falling asleep at night. The teacher must choose between honoring the mother's request, which may have a detrimental effect on the child, or refusing the request, which will have a negative impact on the mother.

Ethical dilemmas are sometimes described as situation that involve two "rights." In the case of the nap, the early childhood educator can conclude that it is morally right to allow a child who needs a nap to nap. But it is also right to keep the child from napping to help a busy mother keep the child on schedule.

When you encounter an ethical issue, it may be helpful to remember that it is either a responsibility or a dilemma—its cannot be both. A characteristic of an ethical dilemma is that it involves deliberation. It can rarely be resolved quickly or by simply applying rules and relying on facts. You won't find easy solutions in any article or book for the dilemmas you face in your early childhood workplace. You can, however, learn to work through these difficult deliberations with guidance from the NAEYC Code. When you are certain that you have encountered an ethical dilemma, you can use the process described in the example that follows to help you find a justifiable resolution.

A discussion of the difference between an ethical responsibility and an ethical dilemma, and the process of ethical analysis, is described in detail in Chapter 3 (pages 27-36) of Ethics and the Early Childhood Educator, second edition. The book also provides examples of how the Code can be applied to a number of dilemmas that recur frequently in early childhood programs.

A New Ethical Issue—“Make sure my child drinks her milk”

Jane, a petite just-turned-3-year-old, is new in Kristen’s class. Jane’s father brings her to school each day at breakfast time.

As required by licensing and the USDA food program, the school serves milk at breakfast and lunch. Like a number of children in the class, Jane refuses milk and drinks water instead. Kristen allows children to make this choice. One day Jane’s father tells Kristen that he and his wife do not want her to allow Jane to drink water until she has drunk at least a full cup of milk. Kristen assures them that she will encourage Jane to drink her milk.

At the next meal, Kristen tells Jane that her family wants her to drink milk so she’ll be healthy and grow strong. Jane sobs uncontrollably. Kristen comforts her and allows her to drink water. She tells Jane she will talk to Jane’s father about letting her drink water. Jane’s eyes grow wide, and she sobs even harder, saying, “Don’t tell Daddy! Don’t tell Daddy!”

Should Kristen honor the wishes of the family or allow Jane to continue to drink water instead of milk? How could she use the NAEYC Code to guide her thinking and decision making in this situation?

The dilemma

This issue’s Focus on Ethics column asks you to consider the story of 3-year-old Jane, whose family does not want her to drink water in school until she has finished drinking her milk. This ethical issue, like others we have presented in previous columns, involves a conflict between requests made by a family member and what teachers think is good practice.

You might use this case as the basis for a staff meeting or an assignment for undergraduate or graduate students, or you might mull it over on your own or with a friend or colleague. We recommend that you use the process we describe in Chapter 3 of Ethics and the Early Childhood Educator to help you reach a well-reasoned response that systematically applies the Code:

1. Determine the nature of the problem

• Is it an ethical issue?
• If it is an ethical issue, does it involve ethical responsibilities or is it an ethical dilemma? (If it is an ethical responsibility, what does the Code mandate that Kristen do? If it is an ethical dilemma, Kristen can seek a resolution using the steps that follow.)

2. Analyze the dilemma

• Identify the conflicting responsibilities.
• Brainstorm possible resolutions.
• Consider ethical finesse finding a way to meet everyone’s needs without having to make a difficult decision.
• Look for guidance in the NAEYC Code. Carefully review its Ideals and Principles—particularly those that apply to responsibilities to children and families.
• Based on your review of the Code and using your best professional judgment, describe what you think is the most ethically defensible course of action in this situation.

When you have finished deliberating on this case and have decided on the best course of action for Kristen, send an email to the coeditors that includes your recommendation and a brief description of how you used the Code to reach this decision.

Information about ethical responsibilities and dilemmas is adapted from two NAEYC books, Ethics and the Early Childhood Educator: Using the NAEYC Code, second edition, and the newly updated Teaching the NAEYC Code of Ethical Conduct: A Resource Guide(forthcoming in spring 2016).

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