2025 – PAGE 446 – ETHICS IN PEDIATRICS
TRUTHFULNESS
Because the parent-patient-doctor relationship is one of trust, truthfulness is another of the foundations. Since the patient and parents trust the doctor to act in their interests, they have a right to be told the truth.
The requirement to tell the truth does not mean that the doctor must always reveal everything, but in 21st century America, truth and transparency are highly valued. An exam answer that involves hiding or distorting the truth is going to be the wrong answer.
CONFIDENTIALITY
Confidentiality respects the patient’s autonomy and privacy. For adults, the duty of confidentiality is nearly absolute, with some limitations involving the duty to protect others. With children and adolescents, it’s more complicated. In general, children do not have a legal right to keep information confidential from their parents. However, there are specific circumstances where they do have that right, depending on their age, whether they are emancipated, and what the medical concern is. For example, confidentiality may be extended to an adolescent for reproductive care, or when the treatment is court-ordered, or when the parent has agreed to allow a confidential doctor-patient relationship. The actual legal boundaries of confidentiality in adolescent care depend on state laws.
When it comes to adolescents, two complementary principles are considered important. The first is that an increasing degree of confidentiality becomes important as adolescents get older so that they will feel free to seek the health care they need. This is especially important in the areas of substance abuse, mental health, sexuality, and reproduction. The second principle is that adolescents should be encouraged to talk with their parents about health-related issues. This must be individualized, since sometimes disclosure would in fact be detrimental to the patient.
General exceptions to confidentiality include:
- Child abuse and neglect
- Suicidal or homicidal ideation
- Violent injuries (where a police report is required)
- STDs which are reportable to the department of public health
- Excessively risky behavior (e.g. habitual drunk driving); the physician’s legal obligation varies by state, but the pediatrician should weigh the ethical duty of confidentiality with the duty to protect life.
PHYSIOLOGIC FUTILITY
This refers to interventions that would likely have no physiologic effect on a disease process. For example, treating a bacterial cellulitis with an antiviral agent, or continuing to perform CPR beyond when it might be successful. The physician does not have an ethical obligation to provide futile (useless) treatments regardless of the parents’ wishes. Treatments might be considered futile because there is no evidence or scientific rationale to support them, because they have already been tried and have failed, or because in the clinician’s opinion they have no likelihood of achieving the desired therapeutic goals. Physicians also have an obligation to refuse to engage in treatment that is not only futile, but harmful.
The provision of food and hydration is generally considered to be no different ethically from medical treatments such as ventilation or antibiotics, and is not required if it is considered to be futile. If nutrition and hydration are not going to improve the patient’s condition, and they are not improving the patient’s comfort, then it is ethically permissible to discontinue them.
PEARL: When trying to decide if something is physiologically “futile,” think about the facts rather than your emotion or your value system. You might “feel” like withdrawing care from a ventilated child in a persistent vegetative state because you feel there is no quality of life, but that is a value-based thought. If the parents feel that the patient does have a good quality of life, and they want the child’s lungs ventilated, you should comply because the ventilator IS having a positive physiologic impact on the lungs. Keeping this line clear will help you immensely with these types of questions on the boards.