Ethical Dilemmas in Pediatrics: Cases and Commentaries
http://www.100md.com
《新英格兰医药杂志》
The discipline of pediatric ethics is growing up. The conventional approach to bioethical analysis does not work with respect to children as it does for adults. The very foundations of bioethics are different when questions arise in the medical care of children, and signs everywhere indicate that this difference is now being recognized. Pediatric ethics programs and centers are being established, national meetings are taking place, research in pediatric ethics is being funded, and books are being published on the subject. One of these books is Ethical Dilemmas in Pediatrics. A multiauthored book covering a wide range of topics related to pediatric ethics, it is clinically relevant, balanced, and thoughtful.
The book is at its best when the contributors disagree with one another. Such disagreement occurs several times and highlights the dialectical tensions that permeate all ethical dilemmas. The book is structured to include cases that elicit comment from a variety of contributors who struggle with issues arising from these cases. At the end of each chapter there is a helpful "topical discussion," in which salient ethical issues are recapitulated.
One weakness of the book is that it sometimes fails to capitalize on the features that distinguish pediatric ethics from the larger field of bioethics. For example, the issue of assent is uniquely complicated in pediatric ethics. Many ethical challenges arise during the ambiguous, transitional stage when children are capable of some involvement in medical decision making but are not fully competent to make decisions regarding their own care. The book pays inadequate attention to the concept of assent and its clinical implications. Similarly, at several different points authors refer to "parental autonomy." This term represents the unwarranted transplantation of a key concept from adult medical ethics into the territory of pediatric ethics, where notions of autonomy exist, if at all, in only a limited way. Because children are separate individuals who merit the same respect and dignity accorded to adults, "parental autonomy" is an oxymoron that neglects the independent fiduciary obligation that health care professionals have toward the children they encounter in the hospital or office. For this reason, parental consent should more appropriately be termed "parental permission." In such areas, ethical clarity demands a more sophisticated analysis than this book provides.
The notion that decisions regarding the care of children should be made on the basis of their "best interests" is an oft-repeated axiom that also deserves a more careful critique than this book offers. Finally, the complicated issues that arise in the conduct of pediatric research are not covered in the book. This omission may be a wise choice by the editors, because there is ample material for discussion in the world of clinical ethics alone, and an attempt to combine discussion of clinical and research ethics in a single book would probably be too ambitious.
Despite several drawbacks, this book has many strengths that allow me to recommend it. The case-based approach provides a helpful launching point for each chapter, and readers are likely to find most of the chapters both informative and thought-provoking. Most of them are focused on common dilemmas that occur in children's hospitals, and these dilemmas will resonate with experienced clinicians. As the field of pediatric ethics matures, I hope that more books of this quality will be published and widely read. In this way, pediatric ethics may help to transform the field of bioethics in the 21st century.
Eric Kodish, M.D.
Cleveland Clinic Foundation
Cleveland, OH 44195(Edited by Lorry R. Franke)
The book is at its best when the contributors disagree with one another. Such disagreement occurs several times and highlights the dialectical tensions that permeate all ethical dilemmas. The book is structured to include cases that elicit comment from a variety of contributors who struggle with issues arising from these cases. At the end of each chapter there is a helpful "topical discussion," in which salient ethical issues are recapitulated.
One weakness of the book is that it sometimes fails to capitalize on the features that distinguish pediatric ethics from the larger field of bioethics. For example, the issue of assent is uniquely complicated in pediatric ethics. Many ethical challenges arise during the ambiguous, transitional stage when children are capable of some involvement in medical decision making but are not fully competent to make decisions regarding their own care. The book pays inadequate attention to the concept of assent and its clinical implications. Similarly, at several different points authors refer to "parental autonomy." This term represents the unwarranted transplantation of a key concept from adult medical ethics into the territory of pediatric ethics, where notions of autonomy exist, if at all, in only a limited way. Because children are separate individuals who merit the same respect and dignity accorded to adults, "parental autonomy" is an oxymoron that neglects the independent fiduciary obligation that health care professionals have toward the children they encounter in the hospital or office. For this reason, parental consent should more appropriately be termed "parental permission." In such areas, ethical clarity demands a more sophisticated analysis than this book provides.
The notion that decisions regarding the care of children should be made on the basis of their "best interests" is an oft-repeated axiom that also deserves a more careful critique than this book offers. Finally, the complicated issues that arise in the conduct of pediatric research are not covered in the book. This omission may be a wise choice by the editors, because there is ample material for discussion in the world of clinical ethics alone, and an attempt to combine discussion of clinical and research ethics in a single book would probably be too ambitious.
Despite several drawbacks, this book has many strengths that allow me to recommend it. The case-based approach provides a helpful launching point for each chapter, and readers are likely to find most of the chapters both informative and thought-provoking. Most of them are focused on common dilemmas that occur in children's hospitals, and these dilemmas will resonate with experienced clinicians. As the field of pediatric ethics matures, I hope that more books of this quality will be published and widely read. In this way, pediatric ethics may help to transform the field of bioethics in the 21st century.
Eric Kodish, M.D.
Cleveland Clinic Foundation
Cleveland, OH 44195(Edited by Lorry R. Franke)