Ethical Decision Making:

1
Ethical Decision Making

• Children and Neonates

2
Medical Decisions Children

• Parents are surrogate decision makers
• Most parents seek the welfare of their children
• Parents should be assisted supported in their
  role as decision makers
• Parents must be mentally competent
• Require necessary information to make an informed
  decision

3
Best interests of child

• ethical and legal standard according to which the
  immature child is to be protected from physical,
  mental, emotional abuse and neglect

4
Determining Best Interests

• Consider
• Is treatment likely to improve childs condition?
• Will condition deteriorate without treatment?
• Weigh anticipated benefits and harms
• Is proposed Tx the least possibly intrusive and
  restrictive?

5
Best Interests Test Parents and Guardians

• Physician cannot treat a child without consent of
  the parent(s)- exception mature minors,
  emergency doctrine
• Parents obliged to provide necessities of life
  for their children
• Parental duty to provide care that is reasonable
  and appropriate

6
Child in Need of Protection Child and Family
Services Act, 1989

• Child in the care, custody, control of one who
• neglects or refuses to provide or obtain medical
  care/treatment necessary for health or well-being
  of the child
• or who refuses to permit such care when
  recommended by qualified medical practitioner

7
Circumstances sufficient to suspend duty to
prolong life (Canadian Pediatric Society)

• Irreversible progression of condition to imminent
  death
• Tx clearly likely to be ineffective or harmful
• Life will be severely shortened regardless of
  treatment and non-Tx will allow for more comfort
  caring
• Intractable and intolerable pain suffering

8
Futility

• Medical treatment seen to be non-beneficial
  because it is believed to offer no reasonable
  hope of recovery or improvement in pts condition

9
Futility

• Quantitative (objective) determined by
  physician
• Qualitative (subjective) determined by patient
  and family

10
Futility- Categories

• Not futile benefits to both physical and overall
  well-being
• Futile Non-beneficial to either physical or
  overall well-being
• Futile from pts perspective medically indicated
  but not valued by pt
• Futile from clinicians perspective valued by pt
  but not medically indicated

11
Futility

• Canadian medical law currently recognizes
  negative right not to have treatment
• Does not recognize positive right to demand
  treatment caregivers view as futile eg.
  Sawatsky

12
Is refusal of CPR justified paternalism?

• Some argue that to offer CPR in futile
  circumstances diminishes autonomy
• Offers choice which is not actually viable
• No DNR does not mean no care