ethical and cultural issues in pediatric care

1. ETHICALAND
CULTURALISSUES
IN PEDIATRIC NURSING

2. PEDIATRIC NURSING
The word Pediatric has derived from two Greek words
‘PEDIS’ MEANS CHILD ‘Iatrike’ means treatment

3. DEFINITION OF
PEDIATRIC NURSING
It is the branch of Medical Science
that deals
conception
with children from
to adolescence in
health & illness. It is driven by the
holistic approach and concerned
with preventive, promotive,
curative and rehabilitative care
of the child.

4. ETHICS:
Greek work:
‘ETHIKOS’
Meaning:
Character
DEFINITION:
Distinction between
RIGHT & WRONG
based on the body of
knowledge.

5. Ethics are influenced by:
Laws
Religion
Scientific Study
Philosophy
Moral

6. PRINCIPLES
GOVERNING
ETHICAL DECISIONS

10. NONMALEFICENCE
◦Based on principles of ‘do no harm’ or ‘Prima
noncore’.
◦Designed to protect patients.
◦Nurse bound to perform selfless beneficial act.
◦Protects Nurse from ill treatment from co-workers.
◦Good effect must not be result of wrongdoing.

11. BENEFICENCE
◦ Obligation of Nurse to advocate patient’s right & interest.
◦ Must remove every harm coming to the patient’s way.
◦ Nurse must invest time and effort towards ethical selfless
acts.
◦ Hurdle lies in different personal perspective, ethnic diversity.
◦ Above all patient’s need to be given priority.

12. PARENTALAUTONOMY
◦Fundamental rights of parents to take full command of
child’s treatment.
◦Parents have freedom to raise concern.
◦Nurse cannot persuade parents but must educate
them.
◦Helps in Evidence based practice.

13. CORRECT MEDICALFACTS
◦Helps parents to take informed decision based on
facts.
◦Nurse must maintain well recorded, unaltered,
unmanipulated medical facts.
◦Accurate medical records facilitate better treatment
plan and benefits the patients.
◦Helps maintaining standards of nursing.

14. justice
◦Every child deserves advanced medical sevices.
◦Nurse distributes health resources without any pre-
occupational ideas.
◦Nurse must ensure cost-effectiveness of therapeutic
measures.
◦Saving life is top priority.

15. VERACITY
o Truth telling is a core professional principle.
oMust tell truth even it causes distress to family.
oHelps maintaining trusted relationship with parents.
oGuide patient to take informed decision.
oTruth telling earns the respect towards the
profession.

16. Ethical dilemma
Clinical problems with ethical implications pose an ever increasing dilemma in everyday medical
practice, and this is particularly the case with ethical issues involving children and those unable to
take their own decisions.
Clinical problems with significant ethical implications pose an ever increasing dilemma in everyday
medical practice in the 21st century and rarely present a simple solution. This is particularly the case
with ethical issues involving children and those unable to take their own decisions.
Whilst the patients’ interests should come first and all personal, cultural and religious bias
eliminated, the impact of costly treatment for the individual patient on the available healthcare
resources must also be taken into account.
Hence it is essential to establish an ethically acceptable code of practice which will allow doctors to
provide an objective approach to management that is both rational and consistent, both for the
child as well as society at large regardless of creed or culture. In this to review some of the general
principles that guide medical ethical problems, whilst the forthcoming series of articles will address
specific ethical issues relating to disability, the initiation of intensive care or ‘extraordinary’
measures and, finally, issues relating to the discontinuation of care and the dying process.

17. The ideal code of ethically acceptable practice may be approached, if not fully achieved, by applying the
following accepted principles in the decision-making process.
1. Respect of the individual's autonomy: Autonomy implies that all are free to take an active and totally
independent role in the decision-making process. For this to occur, patients must be fully informed and
understand the implications of their medical condition, its treatment, complications and outcome. In practice,
however, the vast majority of children do not have the ability to be truly informed, and rely on others for
guidance. If anything, this situation heightens the doctors’ responsibility to ensure true informed consent,
albeit through third parties.
2.

18. 2. Respect of the individual's competence: Competence implies the patient's level of understanding that allows
him or her to weigh up the ethical issues posed by a clinical situation, assimilate these and reach a rational
decision. This degree of comprehension is often a problem with young children, thereby increasing the
responsibility of parents and the medical team to assume the role of competent advocates on their behalf.
3. Respect beneficence: Beneficence defines the medical principle of ‘do no harm’, a hallmark of the
Hippocratic oath, and should apply in all cases. Medical practice frequently entails a compromise between
benefit and harm, especially with regard to interventional procedures and drug therapy, but should always be
biased toward ‘benefit’. Hence, in practice, it may be perfectly acceptable to embark on high-risk therapy in a
fully informed individual (or his/her advocate), provided there is a realistic chance of reasonable benefit.

19. 4. Respect of the truth: There is never a case for wilfully lying to patients. Similarly, there is rarely any
justification in withholding or omitting information from patients.
5. Respect of patient confidentiality: All patients have a right to confidentiality. However, disclosure of
confidential information without consent may be justified in situations where failure to report may lead to
greater disadvantage to the patient (e.g. physical abuse).
6. Avoidance of paternalism and bias Practitioners should strive to remain truly objective and avoid all personal,
racial, cultural, religious or other bias when counselling or treating children. Personal prejudice and
preconceived ideas must never influence the provision or withholding of medical care to patients, regardless of
whether they are disadvantaged, have a pre-existing disability or otherwise. The wishes of parents and
guardians must also be respected, again regardless of any personal bias.

20. 7. Avoidance of all conflicts of interest The patient must always come first, before any vested interest of any
third party including physicians as well as the parents, guardians, extended family and society.
8. Respect the limitations of medical care Medical care should strive to support the patient, and should be
tailored to the needs of the individual including any complications or disabilities. It is ethically appropriate to
appreciate realistic goals which medical care can achieve, and wrong to aim toward exaggerated or impossible
expectations. Hence, it is equally unacceptable to ‘treat at all costs’, as it is to ‘play god’.

21. ISSUES

22. CORRECT
BUT
CONTRADICTORY
EQUALLY
UNSATISFACTORY
ALTERNATIVE

23. o Nursing is a science of uncertainty and art
of probability.
Common Ethical Dilemma:
Inappropriate medication order.
Unresponsive physician
Assignment of tasks before proper exposure
Patients Autonomy Vs Life Threatning condition.

24. REFUSAL TO IMMUNIZATION

25. REFUSAL OF CARE

26. GENETIC THERAPY

27. WITHDRAWAL OF TREATMENT

29. RESTRAINING A CHILD

30. ACCEPTING REALITY

33. EMOTIONAL ATTACHMENT

35. Ethics in the decision-making
process
Given the above accepted guidelines, ethically acceptable decisions can only be based on:

36. CULTURAL ISSUES

37. SOCIO ECONOMIC FACTORS

38. MIGRANT FAMILIES

39. CUSTOMS AND FOLKWAYS

40. FOOD CUSTOMS

41. Muslim Fasting during the holy month of Ramadan: Fasting from sunrise to sundown, beginning
during the teen years. Women are exempted during pregnancy, lactation, and
menstruation and exemptions for illness, but may be associated with a sense of personal
failure.
Inappropriate therapy; will not take medicines
during daytime misinterpreted as noncompliance;
misdiagnosed
Modesty: Women’s body including hair, body, arms, and legs not to be seen by men other
than in immediate family. Female chaperone and/or husband must be present during
exam and only that part of the body being examined should be uncovered.
Deep personal outrage, seeking alternative care
Touch: Forbidden to touch members of the opposite sex other than close family. Even a
handshake may be inappropriate.
Patient discomfort, seeking care elsewhere
After death, body belongs to God: Postmortem exam will not be permitted unless required
by law, family may wish to perform after-death care
Unnecessary intensification of grief and loss
Cleanliness essential before prayer: Individual must perform ritual ablutions before prayer,
especially elimination of urine and stool. Nurse may need to assist in cleaning if patient is
incapable.
Affront to religious beliefs
God’s will: God causes all to happen for a reason, and only God can bring about healing Allopathic medicine will be rejected if it conflicts
with religious beliefs, family may not seek health
care
Patriarchal, extended family: Older male typically is head of household, and family may
defer to him for decision-making
Child’s mother or even both parents may not be
able to make decisions about child’s care;
emergency decisions may require additional time
Halal (permitted) vs harem (forbidden) foods and medications: Foods and medicine
containing alcohol (some cough and cold syrups) or pork (some gelatin-coated pills) are
not permitted
Refusal of medication, religious effrontery

42. Religious Belief Nutrition Medical Care
Buddhism Avoid overfeeding. Some
doctrines are vegetarians. The
use of alcohol and drug is
inconvenient.
Surgeries are frequently
avoided. Cleaning is
important.
Christian Scientist Coffee, some tea forms and
alcohol use are avoided.
Some drugs and other
therapy practices could resist.
They accept physical and
spiritual treatments.
lslamism Ingestion of pork and pork
products and alcohol
forbidden
Treatments are not rejected.
The boys are circumcised.

43. South Asia; Nepal,
Pakistan, Sri
Lanka, Maldives
Religious norms
are very
important.
Sacred water is
sprinkled around
the sickbed and
the patient is
made drink the
sacred water.
Decisions on the
family are taken
by the head priest
and the family
sees death as a
social process.
Bonds between
relatives in the
family are strong.
Specific questions
may be asked to
strengthen
communication
with the family
and the child.

44. THANK
YOU