Primum non nocere is only the beginning

Primum non nocere is only the beginning… ‘First do no harm’ is considered one of the primary ethical principles of medical practice. Originating in a time when physicians made most decisions and options were severely limited, it served well as a touchstone of medical practice. Today, paediatricans are faced daily with complex issues involving clinical and ethical judgement. While the dilemmas experienced in the community paediatrician's office may vary in specific details from those in the neonatal intensive care unit, the ethical principles that guide us to a resolution will be the same. The present article is the first in a new forum intended to provide readers of Paediatrics & Child Health with the opportunity to reflect on ethical aspects, dilemmas and issues that arise in the care of infants, children and adolescents. The heightened awareness of ethics in health care in Canada, and the complexities faced by paediatricians in community practice settings and teaching hospitals, necessitates expanding our ethics armamentarium beyond the basic principles of nonmaleficence (‘do no harm’), beneficence, autonomy and justice to include values such as trust and respect for different social and cultural perspectives. This approach is theoretically inadequate as an approach to ethical reasoning in the context of children and families. Respectful, trusting relationships are fundamental to providing the best possible care. Children are embedded in families, and when a child needs medical treatment, health care providers have the privilege of being invited into the family unit. Families may differ from each other and from their professional health care providers in configuration, parenting norms, values and beliefs. If we are to maintain good relationships with families – which we must do to provide care to their children – we must find ways to recognize and accommodate different views while providing responsible medical advice and treatment. The developing autonomy, values and independence of children and adolescents create ethical challenges as well. Paediatricians may experience conflict between their tendency toward paternalistic protection of their patients who are suddenly young adults, and the recognition that these patients are persons to whom duties of confidentiality, preservation of privacy and respect for treatment decisions are owed. In addition, they may sometimes be placed in the position of having to mediate conflict between adolescent patients and their parents. Several factors have shaped the context in which ethics in health care is currently situated: For the past decade, the Royal College of Physicians and Surgeons of Canada has required residency programs, including paediatrics, to include bioethics in their curricula as a condition of accreditation (http://rcpsc.medical.org/ethics/index.php). The Canadian Council on Health Services Accreditation includes standards related to ethics in informed decision-making and consent, end-of-life care and administration (www.cchsa.ca). We continue to learn more about the effects of social factors, including cultural and religious practices and values, on health and well-being. This is particularly significant in the Canadian context where our deeply held value of respect for diversity, as manifested in parents' decisions for their children, may conflict with our personal or professional view of what is in the child's best interests. Ethics committees and consultants, or bioethicists, are increasingly seen as having an important role in supporting organizations, clinicians, patients and families in ethical decision-making, education and policy development. New medical and scientific knowledge and advances bring with them ethical questions for consideration and investigation, including the generation of economic-related issues such as timely access to care, and regional discrepancies in available services. The pressure to include individual children in research studies, so that children as a group may someday benefit from new safe and effective therapies and drugs, has raised research ethics questions and concerns for consideration by the research community and Research Ethics Boards. Ethical issues in paediatrics are numerous and varied. A cross-Canada group of bioethicists practising in children's hospitals recently identified common topics arising in paediatric ethics consultation (1): Cultural and religious values-based conflicts; Reporting of child abuse; Determining the capacity of a child or adolescent to consent to treatment; Nonadherence to recommended treatment plans; Genetic testing of children; Withdrawal of life-sustaining treatment; Organ transplantation (eg, adolescents as living donors); Conflicts regarding the appropriate treatment for children, especially withdrawal of treatment; Rights and responsibilities of substitute decision makers/professional caregivers; Jehovah's Witnesses and refusal of treatment; Confidentiality (eg, in the care of adolescents); Treatment of patients with eating disorders; and Truthtelling (eg, withholding ‘bad news' from a child). These topics, and the many more that paediatricians, family physicians and other child health practitioners experience in their practice, will be the focus of Ethics in Paediatric Practice. The Editors invite your suggestions for future articles and welcome submissions, which will undergo peer review and revision at the discretion of the Editors and the advice of the CPS Bioethics Committee. Submissions should not exceed 1200 words and should describe an ethical issue or dilemma, and offer a reasoned argument for a conclusion and a practical approach to a resolution. We hope, with your help, to stimulate reflection and discussion about this important aspect of paediatric practice. Thank you to the reviewers of this article for their helpful comments

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