Ethics Articles of Interest

Articles

Paediatric ethical issues during the Covid-19 pandemic are not just about ventilator triage [1], Haward et al. Acta Paediatr 2020 Aug;109(8):1519-1521.

Pediatric modification of the medically necessary time-sensitive scoring system for operating room procedure prioritization during the Covid-19 pandemic [2], Slidell et al J Am Coll Surg 2020 Aug;231(2):205-215.

Ethical, Moral, and Theological Insights into Advances in Male Pediatric and Adolescent Fertility Preservation [3], Ramstein et al Andrology 2017 (5): 631–639.

With the rates of survivorship for children and adolescents diagnosed with cancer improving significantly, focus has shifted towards ensuring a better quality of life for survivors which includes addressing the potential infertility and premature gonadal failure. Pediatric surgeons are often involved in the comprehensive cancer care of their patients and may be asked to participate in fertility preservation initiatives.

Ramstein examines the ethical dilemmas associated with fertility preservation. Despite the focus on sperm banking and testicular tissue cryopreservation, the ethical considerations addressed can be easily applied to both male and female fertility preservation initiatives.

The only pretreatment fertility preservation options for prepubertal males and females are testicular and ovarian tissue cryopreservation – both of which are considered experimental at this point in time. Given the experimental nature there are ethical dilemmas associated with prepubertal fertility preservation initiatives including balancing the risks and benefits of pursuing fertility preservation in the context of starting cancer treatments.

Many of the ethical concerns are rooted in the fact that the child is unable to consent/assent for the procedure and therefore we expect that the parent will act in the child’s best interest. The authors expand on this concept by introducing the idea of preserving a “child’s right to an open future” which they define as upholding the ability for a child to have his/her autonomy preserved until he/she is able to make his/her own independent decisions. With this principle in mind, one may justify pursuing experimental fertility preservation for a prepubertal child as a potential method to provide autonomous, future reproductive options.

The authors also discuss the concern about posthumous reproduction in the setting of cryopreserved gametes and the decisions that have to be made regarding whether tissue is discarded or donated to research after a child’s death.

Single-cell Sequencing of Neonatal Uterus Reveals an Misr2+ Endometrial Progenitor Indispensable for Fertility [4], Saatcioglu et al Elife 2019 Jun 24;8.

Fertility Preservation Options in Pediatric Adolescent Patients with Cancer [5], Burns et al Cancer 2018 May 1;124 (9):1867-1876.

Fertility and Hormone Preservation and Restoration for Female Children and Adolescents Receiving Gonadotoxic Cancer Treatments: A Systematic Review [6], Corkum et al J Pediatr Surg 2019 Jan 22.

A Review of the Oncology Patient’s Challenges for Utilizing Fertility Preservation Services [7], Flink et al J Adolesc Young Adult Oncol 2017 Mar; 6 (1):31-44.

Fertility Preservation in Patients with Cancer: ASCO Clinical Practice Guideline Update [8], Oktay et al J Clin Oncol 2018 July; 36(19):1994-2001.

“Longshot” to “Fantasy”: Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail Weiss and Fiester Amer J Bioethics 2018, 18(1):3-11.

It is not infrequent that pediatric surgeons find themselves struggling with the issue of providing a medically complex treatment plan with a low probability of success in order to support families who are distraught over the possibility of the death of their child. Surgeons may feel pressure to honor a family’s request to “do everything possible” even when it becomes clear that “everything possible” will not be curative. This article offers surgeons the tools needed to help families (and even other health care providers) accept limitations of medical care, clarify the endpoints of interventions and refocus care toward assuring a comfortable death.

“Longshot” treatment options often continue past the point at which curative options are medically feasible. Continued aggressive treatment in this setting may result in harm to the patients, parents and health care team members. In this paper, authors present a structured approach to guiding surgeons and other physicians through this transition from “longshot” to “fantasy” care. The described approach is designed to minimize patient pain, the emotional burden faced by the family and decrease moral distress for the health care team. Two clinical examples are highlighted to illustrate the described approach.

last ditch efforts
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visual abstract courtesy of Sarah Walker

What the “F”? [9], Chen et al Amer J Bioethics 2018. 18(1): 16-18.

Unilateral Withdrawal of Life-sustaining Therapy in a Severely Impaired Child [10], Miller et al Pediatrics 2018.142 (5):1-5.

Navigating Decisional Discord: The Pediatrician’s Role When Child and Parents Disagree [11], Sisk et al Pediatrics June 2017.

Ethical and End of Life Considerations for Neonates Requiring ECMO Support [12], Kirsch and Munson Semin Perinatol 2018 Jan 10.

Informed Consent in Decision-Making in Pediatric Practice [13], Katz et al Pediatrics 2016 Aug;138(2).

Responsible Surgical Innovation and Research in Maternal-fetal Surgery [14], Antiel et al Semin Fetal Neonatal Med 2017 May 24.

Ethics, Emotions, and the Skills of Talking About Progressing Disease with Terminally Ill Adolescents: A Review [15], Rosenberg et al JAMA Pediatr 2016 Dec 1;170(12):1216-1223.

International Variations in Application of the Best-Interest Standard Across the Age Spectrum [16], Laventhal et al J Perinatol 2017 Feb;37(2):208-213.

Parental Refusal of Surgery in an Infant with Tricuspid Atresia [17], Konet al Pediatrics 2016 Nov;138(5).

Two Infants, Same Prognosis, Different Parental Preferences [18], Antommaria et al Pediatrics 2015 May;135(5):918-23.

A Qualitative Study Exploring Moral Distress Among Pediatric Resuscitation Team Clinicians: Challenges to Professional Integrity [19], Thomas et al Pediatr Crit Care Med 2016 Jul;17(7):e303-8.

The ethics of neonatal research: an ethicist’s and a parents’ perspective [20], Janvier and Farlow Semin Fetal Neonatal Med 2015 Dec;20(6):436-41.

The darkening veil of “do everything” [21], Feudtner and Morrison Arch Pediatr Adolesc Med 2012 Aug;166(8):694-5.

Doctor, What Would You Do? An ANSWER for Patients Requesting Advice About Value-Laden Decisions [22], Tucker et al Pediatrics 2015 Oct;136(4):740-5.

Hospital Use in the Last Year of Life for Children With Life-Threatening Complex Chronic Conditions [23], Ananth et al Pediatrics 2015 Nov;136(5):938-46.

Please Do Whatever It Takes to End Our Daughter’s Suffering! [24], Clément de Cléty et al Pediatrics 2016 Jan;137(1):1-6.

References

  1. Haward MF, Moore GP, Lantos J, et al. Paediatric ethical issues during the COVID-19 pandemic are not just about ventilator triage. Acta Paediatr. 2020;109(8):1519-1521.  [PMID:32364256]
  2. Slidell MB, Kandel JJ, Prachand V, et al. Pediatric Modification of the Medically Necessary, Time-Sensitive Scoring System for Operating Room Procedure Prioritization During the COVID-19 Pandemic. J Am Coll Surg. 2020;231(2):205-215.  [PMID:32473197]
  3. Ramstein JJ, Halpern J, Gadzinski AJ, et al. Ethical, moral, and theological insights into advances in male pediatric and adolescent fertility preservation. Andrology. 2017;5(4):631-639.  [PMID:28625022]
  4. Saatcioglu HD, Kano M, Horn H, et al. Single-cell sequencing of neonatal uterus reveals an Misr2+ endometrial progenitor indispensable for fertility. Elife. 2019;8.  [PMID:31232694]
  5. Burns KC, Hoefgen H, Strine A, et al. Fertility preservation options in pediatric and adolescent patients with cancer. Cancer. 2018;124(9):1867-1876.  [PMID:29370455]
  6. Corkum KS, Rhee DS, Wafford QE, et al. Fertility and hormone preservation and restoration for female children and adolescents receiving gonadotoxic cancer treatments: A systematic review. J Pediatr Surg. 2019;54(11):2200-2209.  [PMID:30773394]
  7. Flink DM, Sheeder J, Kondapalli LA. A Review of the Oncology Patient's Challenges for Utilizing Fertility Preservation Services. J Adolesc Young Adult Oncol. 2017;6(1):31-44.  [PMID:27529573]
  8. Oktay K, Harvey BE, Partridge AH, et al. Fertility Preservation in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2018;36(19):1994-2001.  [PMID:29620997]
  9. Chen D, Epstein E, Almarode S, et al. What the "F"? Am J Bioeth. 2018;18(1):16-19.  [PMID:29313770]
  10. Miller KE, Coleman RD, Eisenberg L, et al. Unilateral Withdrawal of Life-sustaining Therapy in a Severely Impaired Child. Pediatrics. 2018;142(5).  [PMID:30315121]
  11. Sisk BA, DuBois J, Kodish E, et al. Navigating Decisional Discord: The Pediatrician's Role When Child and Parents Disagree. Pediatrics. 2017;139(6).  [PMID:28562285]
  12. Kirsch R, Munson D. Ethical and end of life considerations for neonates requiring ECMO support. Semin Perinatol. 2018;42(2):129-137.  [PMID:29331209]
  13. Katz AL, Webb SA, COMMITTEE ON BIOETHICS. Informed Consent in Decision-Making in Pediatric Practice. Pediatrics. 2016;138(2).  [PMID:27456510]
  14. Antiel RM, Flake AW. Responsible surgical innovation and research in maternal-fetal surgery. Semin Fetal Neonatal Med. 2017;22(6):423-427.  [PMID:28551276]
  15. Rosenberg AR, Wolfe J, Wiener L, et al. Ethics, Emotions, and the Skills of Talking About Progressing Disease With Terminally Ill Adolescents: A Review. JAMA Pediatr. 2016;170(12):1216-1223.  [PMID:27749945]
  16. Laventhal N, Verhagen AAE, Hansen TWR, et al. International variations in application of the best-interest standard across the age spectrum. J Perinatol. 2017;37(2):208-213.  [PMID:27735929]
  17. Kon AA, Patel A, Leuthner S, et al. Parental Refusal of Surgery in an Infant With Tricuspid Atresia. Pediatrics. 2016;138(5).  [PMID:27940784]
  18. Antommaria AH, Collura CA, Antiel RM, et al. Two infants, same prognosis, different parental preferences. Pediatrics. 2015;135(5):918-23.  [PMID:25847802]
  19. Thomas TA, Thammasitboon S, Balmer DF, et al. A Qualitative Study Exploring Moral Distress Among Pediatric Resuscitation Team Clinicians: Challenges to Professional Integrity. Pediatr Crit Care Med. 2016;17(7):e303-8.  [PMID:27182784]
  20. Janvier A, Farlow B. The ethics of neonatal research: An ethicist's and a parents' perspective. Semin Fetal Neonatal Med. 2015;20(6):436-41.  [PMID:26497942]
  21. Feudtner C, Morrison W. The darkening veil of "do everything". Arch Pediatr Adolesc Med. 2012;166(8):694-5.  [PMID:22869401]
  22. Tucker Edmonds B, Torke AM, Helft P, et al. Doctor, What Would You Do? An ANSWER for Patients Requesting Advice About Value-Laden Decisions. Pediatrics. 2015;136(4):740-5.  [PMID:26416929]
  23. Ananth P, Melvin P, Feudtner C, et al. Hospital Use in the Last Year of Life for Children With Life-Threatening Complex Chronic Conditions. Pediatrics. 2015;136(5):938-46.  [PMID:26438707]
  24. Clément de Cléty S, Friedel M, Verhagen AA, et al. Please Do Whatever It Takes to End Our Daughter's Suffering! Pediatrics. 2016;137(1).  [PMID:26644491]
  25. Weiss EM, Fiester A. From "Longshot" to "Fantasy": Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail. Am J Bioeth. 2018;18(1):3-11.  [PMID:29313768]