Pediatric Care: A Two Patient System

Pediatric Care: A Two Patient System

“As pediatricians, we actually have two patients: the child and their parents.” A resident physician mentioned this to me, after we had finished rounding on a patient with particularly difficult parents. When I started shadowing in the Pediatrics department at UCLA, I had expected to gain knowledge about medical treatment and observe unique patient cases – and it was incredibly rewarding. However, what I had not expected, was the responsibility of social care pediatricians took upon themselves. Whether that meant looking out for signs of abuse and neglect or providing parents with extensive resources, these doctors dedicated themselves to the general well-being of their patients. These circumstances inspired me to perceive pediatric medicine as it extends beyond medical treatment alone.

The Johns Hopkins School of Medicine conducted a study focused on ethical issues that commonly arise in the setting of pediatric medicine, outlining four areas of focus. The authors of the study point out that, each of these topics supplement the clinical care pediatricians provide. While some of these apply to medical care as a whole, others are specific to pediatric medicine.The first of these areas is “promoting the child’s best interests in complex and resource-poor home and social settings” (Moon et al. 2009). Often, with children who have complicated medical histories, doctors have to be the ones who determine whether their social situations are safe and adequate to provide care. Sometimes, this means taking complicated family dynamics and unique circumstances into account. While it would be easy to simply address patient’s medical needs and send them back home, ethically, the doctor is responsible for ensuring that both the young patients and their caregivers are comfortable with the level of care provided and it suits their personal needs. Based on this, it actually appears that the child and their families are patients.

The next area of focus is “managing the therapeutic alliance with parents and caregivers” (Moon et al. 2009). This point really takes into consideration that pediatric patients have very little agency. Barring extenuating circumstances, doctors are generally confined to the consent and decisions of the caregivers. They are required to accept caregivers’ personal and cultural values. At the same time, they also have to prioritize the medical needs of their own patients. When these two thought processes contradict, this can be a difficult ethical scenario. Consider the case of parents who refuse to consent to a life-saving procedure for their child because it violates their religious values. A doctor would have to respect their wishes, even though their patient’s life would be in danger. In the study, the authors discussed that in order to prevent such contradictory situations from arising, it is important for doctors to maintain trusting relationships with parents from the beginning of a young patient’s care. By doing so, doctors can be stronger advocates for the children, while emphasizing respect for the family’s values.   

The third area of focus is “protecting patient privacy and confidentiality” (Moon et al. 2009). The best example, as explained by the study, of this practice is in young patients’ reproductive health. Often times, patients desire to keep such information confidential from their parents. Doctors are responsible for maintaining this level of privacy, even if it means withholding information from caregivers. This is essential in building a trusting relationship between the doctor and the patient, where the patient will feel comfortable in discussing their health issues with the doctor. However, doctors also have to ensure that keeping this information confidential does not ultimately put the patient’s health in danger. Sometimes, younger patients are not capable of managing their own health. In such situations, pediatricians have to determine how to get adult figures involved, while respecting the wishes and privacy of their patients.

The final area of focus discussed by the study is “using professional authority appropriately” (Moon et al. 2009). Generally, this issue comes up with dealing with providing external resources to patients and their families. It splits into two camps: advocating for the patient and advocating for caregivers, while being fair and honest to both. If doctors notice signs of abuse and neglect, they are responsible for alerting the appropriate authorities and using their positions as medical professionals to determine if the child is in an unsafe or neglectful situation. At the same time, they are also responsible for making sure parents are comfortable with at-home treatment so such situations do not arise. In both cases, physicians have to be careful that their decisions are carried out fairly and within the bounds of adequate medical care.

While medical care has intricate ethical issues, pediatric care adds another layer of consideration because of the convoluted dynamic between doctors, their patients, and caregivers. Ultimately, doctors have to prioritize the needs of their patients, both medically and socially. However, these lines are often blurred because it is also important to respect the values of caregivers. The study mentioned above concludes that it is important for doctors to establish clearly defined relationships with caregivers and keeping them informed about pediatric patients’ health conditions, while respecting the patient’s confidentiality and trust. Of course, this is much easier said than done.

 

SOURCES:

Moon, Margaret, Holly A. Taylor, Erin L. Mcdonald, Mark T. Hughes, and Joseph A. Carrese.

“Everyday Ethics Issues in the Outpatient Clinical Practice of Pediatric Residents.” Archives of Pediatrics & Adolescent Medicine 163.9 (2009): 838.

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