Ethics in Health Care

The ethics of health care and medical decision-making relies on values . Sometimes, ethical decision making in medical care is a matter of choosing the least harmful option among many adverse alternatives. In the day-to-day practice of medicine, although all clinical encounters may have an ethical component, major ethical challenges are infrequent.

The legal system defines the minimal standards of behavior required of physicians and the rest of society through the legislative, regulatory, and judicial systems. Laws support the principle of confidentiality for teenagers who are competent to decide about medical issues. Using the concept of limited confidentiality , parents, teenagers, and the pediatrician may all agree to openly discuss serious health challenges, such as suicidal ideation and pregnancy. This reinforces the long-term goal of supporting the autonomy and identity of the teenager while encouraging appropriate conversations with parents.

Ethical problems derive from value differences among patients, families, and clinicians regarding choices and options in the provision of health care. Resolving these value differences involves several important ethical principles. Autonomy , which is based on the principle of respect for persons , means that competent adult patients can make choices about health care that they perceive to be in their best interests after being appropriately informed about their particular health condition and the risks and benefits of alternative diagnostic tests and treatments. Paternalism challenges the principle of autonomy and involves the clinician deciding what is best for the patient based on how much information is provided. Paternalism under certain circumstances (e.g., when a patient has a life-threatening medical condition or a significant psychiatric disorder and is threatening self or others) may be more appropriate than autonomy.

Other important ethical principles are those of beneficence (doing good), nonmaleficence (doing no harm or as little harm as possible), and justice (the values involved in the equality of the distribution of goods, services, benefits, and burdens to the individual, family, or society).

Ethical Principles Related to Infants, Children, and Adolescents

Infants and young children do not have the capacity for making medical decisions. Paternalism by parents and pediatricians in these circumstances is appropriate. Adolescents (<18 years of age), if competent, have the legal right to make medical decisions for themselves. Children 8-9 years old can understand how the body works and the meaning of certain procedures; by age 14-15, young adolescents may be considered autonomous through the process of being designated a mature or emancipated minor or by having certain medical conditions. Obtaining the assent of a child is the process by which the pediatrician involves the child in the decision-making process with information appropriate to their capacity to understand.

The principle of shared medical decision-making is appropriate, but the process may be limited because of issues of confidentiality. A parent’s concern about the side effects of immunization raises a conflict between the need to protect and support the health of the individual and of the public.

Legal Issues

All competent patients of an age defined legally by each state (usually ≥18 years of age) are considered autonomous regarding their health decisions. To have the capacity to decide, patients must meet the following requirements:

• •
  

  Understand the nature of the medical interventions and procedures, understand the risks and benefits of these interventions, and be able to communicate their decision.

  
  
• •
  

  Reason, deliberate, and weigh the risks and benefits using their understanding about the implications of the decision on their own welfare.

  
  
• •
  

  Apply a set of personal values to the decision-making process and show an awareness of the possible conflicts or differences in values as applied to the decisions to be made.

These requirements must be placed within the context of medical care and applied to each case with its unique characteristics. Most young children are not able to meet these requirements and need others, usually the parent, to serve as the legal surrogate decision maker. However, when child abuse and neglect are present, a further legal process may determine the best interests of the child.

It is important to become familiar with state law as it, not federal law, determines when an adolescent can consent to medical care and when parents may access confidential adolescent medical information. The Health Insurance Portability and Accountability Act (HIPAA), which became effective in 2003, requires a minimal standard of confidentiality protection. The law confers less confidentiality protection to minors than to adults. It is the pediatrician’s responsibility to inform minors of their confidentiality rights and help them exercise these rights under the HIPAA regulations.

Under special circumstances, nonautonomous adolescents are granted the legal right to consent under state law when they are considered mature or emancipated minors or because of certain public health considerations, as follows:

• •
  

  Mature minors. Some states have legally recognized that many adolescents can meet the cognitive criteria and emotional maturity for competence and may decide independently. The Supreme Court has decided that pregnant, mature minors have the constitutional right to make decisions about abortion without parental consent. Although many state legislatures require parental notification, pregnant adolescents wishing to have an abortion do not have to seek parental consent. The state must provide a judicial procedure to facilitate this decision making for adolescents.

  
  
• •
  

  Emancipated minors. Children who are legally emancipated from parental control may seek medical treatment without parental consent. The definition varies from state to state but generally includes children who have graduated from high school, are members of the armed forces, married, pregnant, runaways, are parents, live apart from their parents, and are financially independent or declared emancipated by a court.

  
  
• •
  

  Interests of the state (public health). State legislatures have concluded that minors with certain medical conditions, such as sexually transmitted infections and other contagious diseases, pregnancy (including prevention with the use of birth control), certain mental illnesses, and drug and alcohol abuse, may seek treatment for these conditions autonomously. States have an interest in limiting the spread of disease that may endanger the public health and in eliminating barriers to access for the treatment of certain conditions.