| Abstract |
Ethical maters have been an important part of western medicine at least since the time of Hippocrates. European history is full of laws, rules, and guidelines on the conduct of physicians towards their patients. Examined nowadays, these guidelines seem both modern, since fundamental ethical dilemmas remain the same, and at the same time obsolete, at least in the way physicians think and express themselves on their role. Earlier centuries codes seem to deal mostly with responsibility and privileges connected with the medical identity. According to what was later named and reprimanded as ‘paternalistic model of medical practice’, the physician was essentially duty holder towards the patient, but also the exclusive decision maker. The turn towards the recognition of the patient as a moral agent can be considered as one of the first steps to the evolution of bioethics as a distinct field from its predecessor, medical ethics. Bioethics is emerged in the beginning of the seventies, in a period when the institution of medicine is getting stronger by the day, and technological applications in the medical field are increasing, but doctors’ exclusive authority to decide on ethical matters in medical practice is questioned. Ethical dilemmas resulting from the apply of new technologies in life sciences are approached interscientifically, by physicians, philosophers, theologists, and sociologists, and their resolving is attempted on a basis of four principle of theoretically equal weight, autonomy, non-malefiscence, benefiscence and justice, of which those more fitting are applied and resolve the ethical dilemma in question.
Consequently, physician’s absolute power and authority on the patient is overruled. Moreover, autonomy is emerging as cardinal principle in the physician –patient relationship within the western health system. Validation of patient’s autonomy is performed through the process of informed consent. Through a series of
stages, the patient is informed by the physician on his/ her disease, possible treatments, side effects, alternatives, and freely selects the treatment he or she wishes.
If informed consent as expression of autonomy finds its justification with an autonomous adult, this does not happen with people of reduced of questionable autonomy. In this case, some one else is deciding for the patient (surrogate decision-making). In the case of the child- patient, the situation is more complicated since the patient is at present non-autonomous and protection holder, but he/ she is normally, sooner or later, become fully autonomous. According to Kant’s definition of autonomy, in combination with Piaget’s phychosocial views, an adolescent has the same capacity to obey to universally generalized moral principles with an adult, while Mill favours active promotion and culture of autonomous expression, something which, according to Piaget, may happen from the stage of limited abstract reasoning (7-11 years). The expression of limited to the extent of the child’s possibilities autonomy, his/ her representation from one or more adults, usually, the parents, acting on various criteria, and the apply of non-malefiscence, benefiscence and justice on behalf of the physician perplex decisions on health matters.
In this project, the issue of informed consent in children, is examined through the view of the medical community. Specifically, the question whether this is indeed an issue for the medical community, if physicians are troubled with what pediatric patients or their surrogates want or whether it is a matter of lesser impact for pediatric practice is addressed. For this purpose, a review of the medical literature on informed consent in children was performed. The finding of a large number of relevant articles confirmed the existence of physicians’ interest in the matter, but also created the necessity to limit bibliography and to investigate the subject through specific types of a small number of representative journals. Therefore, through pubMed electronic
library, five established medical journals, New England Journal of Medicine, Lancet, British Medical Journal, Pediatrics, and European Journal of Pediatrics (pediatric or general medical journals from both sides of the Atlantic, traditionally hosting ethical topics) were screened for reviews, editorials, (practice) guidelines, consensus articles, letters and comments on childhood using the key-words consent, assent autonomy, ethics and bioethics.
Literature research finally gave 315 citations categorized in tables for further elaboration and conclusion gathering. A principal conclusion is that medical community is steadily puzzled on pediatric consent. Britain and USA are mainly publishing articles on pediatric consent. There is a difference of the kind of doctors who publish articles, something that may be attributed on the different tradition of the two countries. Regarding the articles’ particular subjects, one may see that a) treatment articles are increasing during the period 87-96, b) there is a strong increase on research articles, c) there is a variation on end life issues with a fall of interest during 87-96 period and a later rise, d) interest for reproduction issues is constantly withering, e) screening and genetic issues appear later in time and f) the subject of consent is tested on neonatal issues also increasing with time.
Examining reference literature through ten year periods, one can see that during 1977-1986 two different attitudes on consent are recognized: the British one, more publicized, where the doctor is assuming more responsibility either recognizing the minor’s autonomy or, in the case of neonates, forming decision with the help of medical councils and committees and the American, less distinct, at the time, where the principal role of parents and state are evident. During the next period, (1987-1996), the two schools are evidently distinct, in their position on the involvement of the minor on treatment decisions and on parental authority to represent while smaller
differences are seen on research articles where child protection prevails. Finally, during the examination of the most recent period (1997-2006), the large number of publications is noted as well as relative converging in the matter of treatment with recognition of minors’ increasing autonomy but also protection from detrimental choices. Furthermore, the cardinal role of research with unresolved issues, despite the effort to set limits, as well as practical differences in dealing with end life, reproduction and genetic issues in Europe and USA are noted during this period.
Focusing on the principal issue of different attitude on pediatric consent in Britain and USA, where increased recognition of the minor’s self determination, greater responsibility assuming on behalf on the physician, and limited parental authority is seen in the first one, while clear authority of the parent as surrogate decision maker, downgraded role of the physician and state control is noted in the second one, it seems that this conclusion is not irrelevant to the two countries’ tradition in the matter of patient autonomy in general. Common law reveals interesting data. In Britain, negligence in consent cases in dispute, is constituted on the standards posed by a body of specialized physicians. On the contrary, in USA, the law is based on the fundamental right of one’s deciding what is to be done to his/ her body. What in Britain is examined as “what is expected from a reasonable doctor to reveal to his patient” is seen in the US as “what is expected from the reasonable patient to know from his doctor”. Consequently, the British recognition of the minor’s competence on the physician’s judgment can be seen as an expression of the authority of the medical body and the possibility to set its own professional standards while American attachment to personal rights makes such a practice inconceivable and demands for someone legally authorized to consent, either the parent or a legally emancipated minor. The conversion of the last period may be showing the increase of
informed consent attitude as well as the adolescent’s competence and increased right for self-determination.
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Η ενήμερη συγκατάθεση (informed consent) των ανηλίκων : η εξέλιξη μέσα από την βιοιατρική και βιοηθική βιβλιογραφία
