Class 6 - Childhood Ethics

Question 1

two “small cases” often seen in childhood ethics

Answer 1

Situation where a child shares a secret with you and do not want you to tell parents

Situations where you have concerns about treatment, or they way people are approaching the child… where the child seems to be resisting and you do not know if the child’s views are being respected adequately

Question 2

4 ways children are disadvantaged

Answer 2

Physically
Smaller and less powerful = making them prone to physical vulnerability
They could be physically exploited and controlled and taken advantage of by bigger, more powerful, older people (‘grown ups’)

Psychologically
They might not have certain types of relational experiences
May not know how to navigate things like trust. How are they supposed to know when they can believe what someone is telling them? When they can cooperate of what someone is asking of them? How do they know when it is safe or unsafe to do so?
With relational experiences we tend to understand how to navigate and read these situations

Socially
They are economically dependent on others for the necessities of living
They can’t sustain themselves, they are dependent on the benevolence of others (commonly their family) to ensure that their basic needs are being met

Legally
Being a minor entails some legal vulnerabilities because they are not independent to act entirely on their own
They cannot independently pursue that their rights are going to be respected adequately
They always require a legal representative, a surrogate, who can act on their behalf and advocate

Question 3

examples that multiply the vulnerability of children

Answer 3

Disabled
Mental health concerns
LGBTQ2A
Newborns
Indigenous
Migrant newcomers
Low income/Poverty
Cultural/religious/racial diversity
Child welfare (youth protection)
Pediatric palliative care
Global child health

Question 4

5 recurring themes (ethical challenges) in nursing children and families

Answer 4

Which criteria determine whether therapies should be provided?
What criteria would be ethically correct
How do we judge that?

Who should make such decisions?
Who should have the authority to decide what healthcare approach is ethically optimal for the particular child ?

What about the voice of the child?
Where does their voice fit in?
Does the voice of the child always matter? Does age and so called maturity? Capacity?
Do some children’s voices merit more ethical grounds for being respected than other children? How do we figure that out?

What about confidentiality?
Are children owed a respect for privacy and confidentiality?
Are we bound to respect their wishes when they say “do not tell my parents”?

Considerations in pediatric palliative care
How do we relate end of life or other types of palliative care challenges that children confront … .how does good ethical nursing navigate these situations?

Question 5

Help define what type of norms we ought to be drawing on in order to help clarify what would be the ethical superior way forward

Answer 5

statement from the Canadian Pediatric Society

Question 6

3 important statements from the Canadian Paediatric Society Position Statement “Tx decisions regarding infants, children and adolescents”

Answer 6

All infants, children and adolescents – regardless of physical or mental disability - have dignity, intrinsic value, and a claim to respect, protection, and medical treatment that serves their best interests.

In most cases, parents are appropriate surrogate decision makers for their children and should give primacy to the best interests of their child.

Children and adolescents should be appropriately involved in decisions affecting them. Once they have sufficient decision- making capacity, they should become the principal decision maker for themselves

Question 7

why is Qb different from other provinces

Answer 7

All other provinces are not the same, but they are rooted in Common Law which we do not have in Quebec.

In Quebec it varies quite a lot because it is a Civil Code system, so the way the law operates is quite different

Question 8

Medical decision-making in paediatrics: Infancy to adolescence
(name a few key points from the Canadian Paediatric Society)

Answer 8

Children’s/ adolescents’ participation in medical decision-making should besought in proportion to developmental capacity to understand nature & consequences of their medical problem and to reasonably foreseeable risks & benefits of treatment proposed

HCPs & SDMs should be informed about, and act in accordance with, laws and regulations governing consent to treatment within their jurisdiction

HCPs must provide patients and their SDMs with all the information they need to participate effectively in the decision-making process

Assent/dissent should be respected whenever possible; it is recognized that in absence of capacity, minimizing harms & maximizing patient’s best interests is the priority

HCPs, patients & families should work together to reach medical decisions based on the patient’s best interests or outcomes

In cases of serious disagreement/competing interests, HCP’s primary responsibility is to the patient

In complex social situations, a collaborative process should be agreed upon to clearly identify the SDM(s) in a timely fashion

HCPs should be aware of conflict resolution process in place in their practice environment In situations of conflict, HCPs have an obligation to seek and access resources to help resolve that conflict & to facilitate patient and family access to such assistance as well

Question 9

Which criteria should determine whether therapies ought to be provided?
(2)

Answer 9

Child’s best interests

Proportional weighing of benefits and burdens

Question 10

What does best interest mean?

Answer 10

There is not one clear universal definition. In general, it is widely agreed that the best interest implies the course of option where the benefits are proportionally greater to the burdens.

Question 11

Which benefits and burdens are most important - when we are discussion best interest?

Answer 11

We do not have a universal consensus on that

We know that many families have relative differences on quantity of life in relation to quality of life

Some families, whether it is cultural, religious or just personal convictions; might believe that prolonging life (even for another day) is always worth it - no matter how intrusive some of the treatments might be

For some families, quality of life is important. They do not view doing very intrusive things as worth it if the QOL during treatment is going to be severely difficult, and the long term outcome is going to be compromised in relation to what the parent’s aspirations are and the parent’s conception of what is best for the child would be.

Gets into very sensitive topics relating to how do different forms of disability, and other types of outcomes, matter in terms of a child’s best interest (**in recent years interesting work on this area)

Question 12

Who should decide which treatment is best?

Answer 12

Legally, the person with the ultimate authority on what course of Tx would optimize the child’s best interest, in the context of Canadian Jurisdiction, would be the parents.

When it comes to consenting to treatment, the authority commonly would be the parent. In certain circumstances it could be the child.

All the others who are involved in the duty of care to the child (physicians, nurses, RT, psychologist, social workers, etc) also have to make decisions on what is in the child’s best interest, in how they make decisions about their own actions.

Ultimately, in deciding what will be the goals and the master care plan here = the parents or person’s with parental authority are the legal decisions makers

Question 13

Consent (adapted)

Answer 13

There are certain standards in which the child is recognized as being capable, or in fact required to consent to treatment. Either independently or sometimes with parenteral collaboration.

This is specified by law in every jurisdiction

Question 14

Assent

Answer 14

Even when the child is not of that age or threshold of capacity to decide for themselves, within childhood ethics, many have been promoting recognizing the child’s capacity to ASSENT to care.

Assent is NOT consent

Ultimately, you may still do certain things to a child without their consent. We will try the best we can to elicit their voluntary cooperation

So if a younger child is not legally allowed to provide consent = a legal standard. We then provide in Childhood Ethics is a way of recognizing the younger child as a person, they still have a voice and a say in how they will be treated to the extent of what is possible and realistic to their voluntary collaboration

An ethical analysis has been able to make a compelling case that we can still move forward with this intervention regardless of the child’s dissent (clear expression of rejection). Regardless, we would have done the best we can to be mindful of the child’s preferences

Question 15

what is our responsibility to the parents of a child who is 14 or over and hospitalized for > 12 hours?

Answer 15

The civil code allows us and requires us that we breach the privacy and confidentiality of the child in a narrow way = in the chance that they would be hospitalized for 12 hours or more

We have an obligation, and the parent’s have a right to know this

Only to know that the child is there

Does not allow us to explain any of the circumstances related to the child’s condition, health and so on; UNLESS the child is unconscious, illness or medication has rendered them incapable of deciding for themselves → in that case the parent would be the decision maker for the child and should received required information, ONLY the information required for them to make Tx decisions for that minor

Question 16

Health Care Consent Act (Ontario)

Answer 16

No specific age set for determining at what point does a child decide for themselves

In Ontario, authorization to consent independently is tied to the decision making capacity of that person

Any person who is able to understand the information that is relevant to making the decision, and can reasonably appreciate the foreseeable consequences of that decision, if they meet those standards, they are deemed and judged as being decisionally capable = can make decisions for themselves

When we are referring to a minor who meets this description, in a **Common Law jurisdiction (every province but Quebec), it is referred to as mature minor **

Question 17

Mature minor

Answer 17

A minor who has demonstrated decision making capacity

They can make decisions independently (ex: can refuse a blood transfusion), can make decisions about any Tx, refuse any Tx without parent or parenteral corroboration; and without parents necessarily being informed (**changes province to province)

There are certain situations in which parents might also be required to oversea if that child’s best interests are still being served and the child is making decisions that do not threaten their own best interest

Question 18

is capacity an all or nothing concept in the Health Care Consent Act of Ontario?

Answer 18

Capacity depends on treatment
15. (1) A person may be incapable with respect to some treatments and capable with respect to others

Question 19

Consent to Treatment: Minors

College of Physicians and Surgeons of Ontario (Policy Statement #3-15)

Answer 19

The test of capacity to consent to a treatment is not age-dependent and as such, physicians must make a determination of capacity to consent to treatment for a minor just as they would for an adult. If a minor is capable with respect to a treatment, the physician must obtain consent from the minor directly even if the minor is accompanied by his or her parent(s) or guardian(s).

Capacity to consent not dependent on age

Physicians and other clinicians, in the clinical relationship with the minor, have to make a determination that they have a capacity to consent

Question 20

Clarification on ‘Consent’

Answer 20

Everything you do, you have to continuously explain

Consent relates to all aspects of care, not just the medical plan decisions

Consent is processual and continuous

Everyone who is performing a clinical intervention relating to a child = always requires consent

Question 21

Why is Health Care Consent Act of Ontario helpful?

Answer 21

Because it provides us with a definition of best interest (as advised by Ontario Law)

Many would agree this is quite transferable to other jurisdictions.

However, this is an Ontario law and certainly bears weight in Ontario but provides us with a useful definition of best interest.

Quebec law does not have an explicitly stated definition like this of best interest

Question 22

Health Care Consent Act (Ontario)
Best interests

Answer 22

(2)In deciding what the incapable person’s best interests are, the person who gives or refuses consent on his or her behalf shall take into consideration,

(a)the values and beliefs that the person knows the incapable person held when capable and believes he or she would still act on if capable;

(b)any wishes expressed by the incapable person with respect to the treatment that are not required to be followed under paragraph 1 of subsection (1); and

(c)the following factors:
1. Whether the treatment is likely to,

i. improve the incapable person’s condition or well-being,
ii. prevent the incapable person’s condition or well-being from deteriorating, or
iii. reduce the extent to which, or the rate at which, the incapable person’s condition or well- being is likely to deteriorate.

2.Whether the incapable person’s condition or well-being is likely to improve, remain the same or deteriorate without the treatment.
3.Whether the benefit the incapable person is expected to obtain from the treatment outweighs the risk of harm to him or her.
4.Whether a less restrictive or less intrusive treatment would be as beneficial as the treatment that is proposed.

Question 23

Exceptions for Parental Consent/Permission

Answer 23

Mature minor (sufficient maturity to consent)

Emancipated minor (with adult rights – eg, married minor)

Emergency treatment

Court ordered treatment

Question 24

“Mature Minor” in Canadian Law falls until what type of law?

Answer 24

Common Law concept

No universally accepted definition

Person under the age of majority with

Capacity to make an informed healthcare decision + Independence to make voluntary decision

NB: Healthcare decision-making capacity of minors is not solely determined by age but tied to evolving maturity

Question 25

Within childhood ethics, many promote the idea of

Answer 25

assent and personhood

Question 26

Attend to the moral voices of children while recognizing limits to the responsibility that they can assume

Answer 26

Interpreting the standard of child assent more broadly.

Question 27

Assent implies:

Answer 27

1.Optimizing the child’s understanding of his/her condition and proposed tests and treatments.

2.Seeking the child’s voluntary cooperation to the proposed care.
To the greatest extent possible

Question 28

is communication impairment an appropriate term?

Answer 28

The term impairment is not preferred for those working with youth and the disabled because that is characterizing their particularities as a kind of deficiency.

Question 29

is childhood agency an independent concept?

Answer 29

Recognizing childhood agency as relationally embedded

Parents can help translate voices for some children = Parents are an important tool

oung people who communicate differently, would normally apply participation of the parents as a communication interlocutor (interpreter) - especially those children that communicate differently

Question 30

In quebec, if the pt X , you owe them confidentiality unless they are in serious risk of harm

Answer 30

14 years old

Question 31

Confidentiality

Condition for disclosure AND extent of disclosure

Answer 31

Condition for disclosure
- Clear risk to identifiable person or group of persons
- Serious risk of bodily harm or death
- Imminent danger

Extent of disclosure
Limited in proportion to imminent risks

Question 32

what group of children do we excessively dismiss in practice?

Answer 32

Newborns