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INTRODUCTION

The ethical and moral dimensions of health and medicine pervade all aspects of clinical care. Providers of hospital care for children constantly encounter situations in which ethical considerations are vital, ranging from the routine task of obtaining parental permission for medical care to more rare quandaries regarding care deemed necessary (yet is refused) or futile (yet is requested). Competence in handling ethically problematic situations can be enhanced by expanding one’s perspective on ethical thinking, knowing what institutional resources are available to help resolve ethical problems, and learning how to approach specific common problems.

ETHICAL PERSPECTIVES

RULES AND POLICIES

There are many ways to approach ethical decision-making. An important practical starting point is the hospital’s rule or policy providing specific instructions regarding the issue at hand. For instance, hospitals typically provide guidance about when the general consent for care granted by a parent at the time of admission is inadequate and specific parental permission to perform certain diagnostic or therapeutic procedures must be obtained and documented. Such rules and policies can often be found in the medical staff bylaws or in national guidelines published by the American Academy of Pediatrics (AAP), American Medical Association, or other organizations. Ethically problematic situations are addressed by asking, “What rules and policies [or pertinent state or federal laws] govern our conduct and guide our choices?”

DUTIES, RESPONSIBILITIES, AND COMMITMENTS

Consideration of professionally defined duties and responsibilities can help guide decisions. A growing movement within medicine emphasizes the importance of professional duties, responsibilities, and commitments toward such ends as professional competence, just distribution of finite resources, the integrity and advancement of scientific knowledge, honesty with patients, patient confidentiality, maintenance of appropriate relations and boundaries with patients, improvements in quality of care and access to it, and maintenance of trust by managing conflicts of interest.1 To the degree that such commitments reflect professional consensus, they function as informal policies and guide our actions by telling us (less explicitly than policies) how to behave.

VIRTUES OR PERSONAL TRAITS

An allied approach to ethics focuses on individual character traits such as honesty, compassion, competence, fortitude, temperance, fidelity, integrity, self-effacement, and wise and prudent decision-making. Here, however, the emphasis shifts away from what constitutes good behavior (which is the focus of policies or duties) and toward what constitutes a good person who will behave virtuously.2 When confronting ethically problematic situations, personal traits can be used to evaluate a proposed course of action: if I behave in this manner, will I be acting with honesty, fidelity, and fortitude? If not, why would I pursue this course of action? Can I chart another course with greater integrity and wisdom?

BIOETHICS PRINCIPLES

To analyze what would be the “right” course of action, it may also be useful to consider the frequently ...

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