Newborn health benefits or financial risk protection? An ethical analysis of a real-life dilemma in a setting without universal health coverage

INTRODUCTION

High healthcare costs make illness precarious for both patients and their families' economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.

METHODS

Using a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.

RESULTS

Giving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties-the newborn, family members and health worker-cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people's substantive freedoms.

CONCLUSION

In settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty.

Ethical considerations for the design and implementation of child injury prevention interventions: the example of delivering and installing safety equipment into the home

INTRODUCTION

Public health ethics is a growing field of academic interest but ethical discussion of injury prevention seems to have received limited attention. Interventions that promise to be effective are not necessarily-without explicit justification-'good' and 'right' interventions in every sense. This paper explores public health ethics in the context of child injury prevention with the objective to initiate interdisciplinary dialogue on the ethics of child safety interventions.

METHOD

A framework of seven public health ethics principles (non-maleficence, health maximisation, beneficence, respect for autonomy, justice, efficiency and proportionality) were applied to an intervention to promote child safety in the home.

RESULTS

Preventing child injury in the home is ethically challenging due to the requirement for the state to intervene in the private sphere. Non-maleficence and beneficence are difficult to judge within this intervention as these are likely to be highly dependent on the nature of intervention delivery, in particular, the quality of communication. Respect for autonomy is challenged by an intervention occurring in the home. The socioeconomic gradient in child injury risk is an important factor but a nuanced approach could help to avoid exacerbating inequalities or stigmatisation. Equally, a nuanced approach may be necessary to accommodate the principles of proportionality and efficiency within the local context.

CONCLUSION

We conclude that this intervention is justifiable from an ethical perspective but that this type of reflection loop is helpful to identify the impact of interventions beyond effectiveness.

The Conundrum of Children in the Us Health Care System

One area in which children’s rights are rarely considered in the USA is that of autonomy over their bodies. This right is routinely ignored in the arena of health care decision making. Children are routinely excluded from expressing their opinions involving medical decisions that affect them. This article discusses the complex reasons why children’s voices are typically not heard in the USA, the consequences of their disempowerment, and the ethical obligations of health care providers to advocate for the rights of children, even in the absence of a legal mandate to do so.

The Potential Value of the U.N. Convention on the Rights of the Child in Pediatric Bioethics Settings

This article provides support for the use of a particular international human rights law document, the U.N. Convention on the Rights of the Child (CRC), in contemporary pediatric bioethics practice without relying on the legally binding force of the document. It first demonstrates that the CRC's core commitments and values substantially overlap with the core commitments and values of mainstream bioethics and with the laws of many domestic jurisdictions where mainstream bioethics are currently practiced. It then explores some implications of this overlap. For instance, the substantial international human rights law scholarship on how to understand these commitments and values can be helpful in suggesting ways to operationalize them in domestic bioethics practice and can offer insightful, internationally generated ethical perspectives that may not have been considered. The article also argues that the CRC can help health-care organizations develop policies consistent with the best interests of children and that the CRC can serve as a common language of values for transnational health-care collaborations. However, as a final case discussion demonstrates, whatever the merits of the CRC, one may face practical difficulties in trying to use it.

Child Rights and Clinical Bioethics: Historical Reflections on Modern Medicine and Ethics

Why might pediatric bioethicists in the United States reject the U.N. Convention on the Rights of the Child (CRC) as a framework for resolving ethical issues? The essays in this issue present arguments and counterarguments regarding the usefulness of the CRC in various clinical and research cases. But underlying this debate are two historical factors that help explain the seeming paradox of pediatric bioethicists' arguing against child's rights. First, the profession of clinical bioethics emerged in the 1970s as one component of modern medicine's focus on improving health through the application of technologically sophisticated treatments. The everyday work of U.S. bioethicists thus usually involves emerging technologies or practices in clinical or laboratory settings; the articles of the CRC, in contrast, seem better suited to addressing broad policy issues that affect the social determinants of health. Second, U.S. child health policy veered away from a more communitarian approach in the early 20th century for reasons of demography that were reinforced by ideology and concerns about immigration. The divide between clinical medicine and public health in the United States, as well as the relatively meager social safety net, are not based on a failure to recognize the rights of children. Indeed, there is some historical evidence to suggest that "rights language" has hindered progress on child health and well-being in the United States. In today's political climate, efforts to ensure that governments pledge to treat children in accordance with their status as human beings (a child right's perspective) are less likely to improve child health than robust advocacy on behalf of children's unique needs, especially as novel models of health-care financing emerge.

Actions Speak Louder Than Words: The U.N. Convention on the Rights of the Child and U.S. Pediatric Bioethicists

In exploring the relationship between "child rights" and "pediatric bioethics" and how these disciplines might provide mutual support in advancing the health and wellness of children around the world, our article responds to the questions of whether the U.N. Convention on the Rights of the Child (CRC) could be of any benefit in the United States, the only country that has not yet ratified this international treaty, and whether the CRC has any value for addressing clinical pediatric bioethics' questions. We describe the considerable influence that the United States had in developing significant components of the CRC, and we argue that the CRC may be useful for U.S. pediatric bioethicists as a tool to advance children's health policy. We note that ratification of the CRC does not equate with compliance or success. Lastly, we identify a distinction between the use of the term "best interests" by child rights advocates and its use by clinical pediatric bioethicists.

The U.N. Convention on the Rights of the Child: Relevance and Application to Pediatric Clinical Bioethics

This article provides an overview of the relevance and import of the U.N. Convention on the Rights of the Child (CRC) to child health practice and pediatric bioethics. We discuss the four general principles of the CRC that apply to the implementation of all rights contained in the document, the right to health articulated in Article 24, and the important position ascribed to parents in fulfilling the rights of their children. We then examine how the CRC is implemented and monitored in law and practice. The CRC and associated principles of child rights provide strategies for rights-based approaches to clinical practice and health systems, as well as to policy design, professional training, and health services research. In light of the relevance of the CRC and principles of child rights to children's health and child health practice, it follows that there is an intersection between child rights and pediatric bioethics. Pediatric bioethicists and child rights advocates should work together to define this intersection in all domains of pediatric practice.

Toward a Child Rights Theory in Pediatric Bioethics

This article offers a child rights theory in pediatric bioethics, applying the principles, standards, and norms of child rights, health equity, and social justice to medical and ethical decision-making. We argue that a child rights theory in pediatric bioethics will help pediatricians and pediatric bioethicists analyze and address the complex interplay of biomedical and social determinants of child health. These core principles, standards and norms, grounded in the U.N. Convention on the Rights of the Child (CRC), provide the foundational elements for the theory and a means for better understanding the complex determinants of children's health and well-being. Rights-based approaches to medical and ethical decision-making provide strategies for applying and translating these elements into the practice of pediatrics and pediatric bioethics by establishing a coherent, consistent, and contextual theory that is relevant to contemporary practice. The proposed child rights theory extends evolving perspectives on the relationship between human rights and bioethics to both child rights and pediatric bioethics.

Following the Yellow Brick Road: Next Steps in the Synthesis of Pediatric Bioethics and Child Rights

The Symposium on "The Interface of Child Rights and Pediatric Bioethics in the Clinical Setting" brought together a diverse group of pediatric bioethicists and child rights advocates to explore how the junction of these disciplines could inform their respective work. In retrospect, it is clear how the diversity of personal histories, professional disciplines, knowledge, experience, language, culture, and politics of the participants influenced the outcomes of the Symposium and provided both challenges and opportunities for further collaboration. Several themes emerged from the meeting, including the relevance of the U.N. Convention on the Rights of the Child (CRC), the role of the family, and consideration of the best interests of the child to complex medical decision-making; research ethics; and the applicability of the principles of bioethics and child rights to the social determinants of health. This essay poses questions related to each of these themes that can serve as a framework for further collaboration. It concludes with a statement by Da Silva and his coauthors that the CRC and the principles of child rights can provide "increased conceptual clarity and a widely endorsed language that can assist pediatric bioethicists in clinical, organizational, and international consultations, as well as in education and policy development."

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care

Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves.

Advance Care Planning: practicalities, legalities, complexities and controversies

Increasing numbers, complexities and technology dependencies of children and young people with life-limiting conditions require paediatricians to be well prepared to meet their changing needs. Paediatric Advance Care Planning provides a framework for paediatricians, families and their multidisciplinary teams to consider, reflect and record the outcome of their conversations about what might happen in the future in order to optimise quality of clinical care and inform decision-making. For some children and young people this will include discussions about the possibility of death in childhood. This may be unexpected and sudden, in the context of an otherwise active management plan or may be expected and necessitate discussions about the process of dying and attention to symptoms. Decision-making about appropriate levels of intervention must take place within a legal and ethical framework, recognising that the UK Equality Act (2010) protects the rights of disabled children and young people and infants and children of all ages to the same high quality healthcare as anyone else.

The practice of evidence-based treatments in ethnic minority youth

Ethnic minority children continue to have substantial unmet mental health needs, and evidence-based treatments (EBTs) have proved challenging to disseminate widely among ethnic minority communities. Indeed, policy makers have made an important distinction between EBTs, interventions that have proven efficacy in clinical trials, and evidence-based practice, which involves "the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences." The present research evidence suggests that several interventions have been found to be effective in ethnic minority populations without a need for major adaptations of the original interventions. However, this article highlights the need to deliver evidence-based practice, which is defined as the implementation of EBTs delivered with fidelity and with the integration of important cultural systems and community factors.

Racial and ethnic disparities in pediatric mental health

Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This article offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types, and treatment outcomes. The authors address relevant factors in the family, community and socioeconomic context, and describe various local and national programs that aim to tackle the obstacles and fill the gaps in high-quality care for racial/ethnic minority youth. The article concludes by offering recommendations for improvement that acknowledge the importance of understanding preferences and attitudes toward treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.

Politically-motivated torture and child survivors

It is critical that healthcare providers recognize behaviors common to children who have endured politically-motivated torture in order to create a safe and reliable treatment plan for such children and their families. Three vignettes taken from actual cases illustrate the way child survivors of torture are likely to present in educational, medical, or healthcare settings. Children or youth are resilient and can be helped to process their traumatic experiences and thrive emotionally and physically if providers are observant, competent and responsive. Federally funded resource centers exist to assist in caring for children who have survived torture.

Interpreter services in pediatric nursing

A critical part of every encounter between a pediatric nurse and a patient is obtaining accurate patient information. Unique obstacles are encountered when patients and their families have little or no understanding of the English language. Federal and state laws require health care systems that receive governmental funds to provide full language access to services. Both legal and ethical issues can arise when caring for non-English-speaking patients. Often, obtaining accurate patient information and a fully informed consent cannot be done without the use of an interpreter. The interpreter informs the family of all the risks and benefits of a specific avenue of care. When inappropriate interpreter services are used, such as when children in the family or other family members act as interpreters, concerns about accuracy, confidentiality, cultural congruency, and other issues may arise. The purpose of this article is to: (a) explore principles related to the use of medical interpreters, (b) examine different models of interpreter services, and (c) identify available resources to assist providers in accessing interpreter services (e.g., books, online resources, articles, and videos). The case study format will be used to illustrate key points.

Consent and participation: ethical issues in the treatment of children in out-of-home care

Mental health service (MHS) providers confront questions of informed consent for evaluation and treatment of children in state custody who are placed in residential or foster care programs, where legal responsibility is shared between state and parent. There are ethical issues encountered by MHS providers who work with this growing population of children in placement. Matters of informed consent and access to information about treatment influence relationships with the parents, legal guardians, Child Protective Service workers, and the child. These specific concerns are addressed: informed consent, the right to be informed, and the rights of parents or foster carers to participate in a child's treatment. Recommendations for resolving dilemmas faced by MHS providers are discussed.

Ethical issues in public health: a qualitative study of public health practice in Scotland

STUDY OBJECTIVE

To identify ethical issues encountered by staff in the development and implementation of public health activities at two sites in Scotland.

DESIGN

Qualitative research study involving face to face semi-structured interviews with participants.

SETTING

A public health directorate in a National Health Service Trust, and a public health demonstration project in child health.

PARTICIPANTS

Health promotion specialists, managers, nurses, public health consultants and specialists, researchers, trainees, and other public health staff.

MAIN RESULTS

Three main categories of ethical issues were identified: paternalism, responsibilities, and ethical decision making. Consulting with the community and sharing information raised issues of paternalism and honesty. Participants identified multiple and sometimes conflicting responsibilities. Barriers to fulfilling responsibilities included meeting targets, working with partners, and political influences. Defining the limits of responsibilities posed challenges. Participants identified values for ideal decision making, but lack of time often led to a more pragmatic approach.

CONCLUSION

These empirical findings complement and extend existing discussions of public health ethics, emphasising the complex nature of ethical issues in public health. The implications for public health policy and future research are discussed.

Stretching the limits of "rights talk": securing health care entitlements for children

Health care rights by their very nature have to be considered not only in a traditional legal context structured around the ideas of human autonomy but in a new analytical framework based on the notion of human interdependence. "A healthy life depends upon [social] interdependence: the quality of air, water, and sanitation which the [state] maintains for the public good; the quality of one's caring relationships, which are highly correlated to health; [as well as] the quality of health care and support furnished officially by medical institutions and provided informally by family, friends, [and the community]."

Ethics and children's rights: learning from past mistakes

The primary aim of this article is to examine, within the context of recent controversial child health practice and research, the underlying philosophy of the aspect of the Nursing and Midwifery Council's Code of Professional Conduct which states that: 'You are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political belief.' A description of the Nuremberg Code, the Helsinki Declaration, the United Nations Convention on the Rights of the Child, and the Human Rights Act 1998 will form the backdrop to this article and a range of contemporary examples will be used to illuminate the ethical dilemmas facing children's nurses in their day-to-day work. Within this context the four major principles that underpin healthcare this will be investigated and the legacy of historical unethical practice and research acknowledged. The vulnerability of children and their families to potential coercion, and the role of local research ethics committees, will be discussed.