2025 – PAGE 447 – ETHICS IN PEDIATRICS
QUALITATIVE FUTILITY
This refers to interventions that would not improve, or might decrease, the quality of life of a patient. Your idea of “quality of life” is based on your own values. A child’s parents may have different values than yours. Keep this in mind when discussing treatments that you believe would be “futile” with the parents of a child.
Unfortunately, these cases are not clear cut. Conflict can arise between the pediatrician and the parents, between the pediatrician and other staff, and between the parents themselves. When that happens, a “due process” should be used to consider the different perspectives and try to reach a consensus. It may be helpful or necessary to involve a formal medical ethics consultation or involve the institutional ethics committee.
PEARL: For the exam, think about “risk versus benefit.” If an answer choice is presented that will “do no harm” to the patient and allow further discussion to take place, choose that answer over one that is based on your value system around the idea of “quality of life.”
SPECIFIC ISSUES
IMPAIRED NEUROLOGIC STATES
Brain death: irreversible loss of all brain function including brainstem activity. A person who is determined to be brain dead is legally and ethically dead, so any medical treatment is by definition futile. There may be other reasons such as organ donation to give treatment.
Persistent vegetative state (PVS): a state of unconsciousness, lack of awareness, lasting for more than a month. Has sleep cycle, eye opening and closing, but no communication, no evidence of purposeful activity. Recovery is less likely the longer a person has been in the state. Ethical issues may come up about whether a treatment benefits the patient, since there is no consciousness and little or no prospect for recovery.
PEARL: For the exam, if a treatment will not help the body, it is futile. If a family wants a treatable condition treated because they want their loved one to continue living, always treat. An ethics consultation, and other discussion with the family, can always be considered later.
Minimally conscious state: a state with clear but fluctuating evidence of consciousness. The person might speak, show recognition, or act purposefully very briefly and with no reproducible pattern. Can be confused with PVS unless the patient is being observed carefully and reports of brief consciousness are taken seriously. Unlike in PVS, the neural network for consciousness is still intact to some degree and there is a prospect for recovery. Ethical considerations can surround the fact that the patient has some awareness and has a prospect of recovery.