Addressing ethical issues in everyday practice

In primary-care practice, just as in critical care, ethical dilemmas challenge pediatricians to make choices in the best interests of their patients. Parents are important to the growth and development of children and have broad responsibility for making virtually all decisions regarding nutrition, clothing, housing, education, religion, and medical care. Society's deference to parental choice promotes the value of family integrity, ensures the availability of an identifiable decision maker, and acknowledges the legitimate role parents play in shaping their child's development. However, pediatricians have obligations to assess and advocate for the best interests of their patients. This requires that physicians reach out to their patients and take the time to listen to children and to involve them in their own care. The proper role of a child in planning care depends less on chronologic age than on developmental and personal capacity. Even young children have a keen awareness of their own clinical situations and options and should be involved as best as is possible in decision making. All decision making for children should be collaborative among patients, parents, and professionals. A situation including an involved child, an informed parent, and a caring and compassionate caregiver working collaboratively is most likely to result in optimal decisions for pediatric patients. Bartholome concluded in 1995 that pediatricians should respect children for the persons they are in the process of becoming by being willing to assist them to participate to the extent of their capacity in making decisions about their health. Combining that view with fostering respect for the strongly held beliefs and values of parents is the direction pediatricians should travel to make decisions in the best interests of children.