This document discusses several key ethical issues in child health nursing including autonomy, beneficence, nonmaleficence, justice, veracity, fidelity, informed consent, assent, disent, advance directives, and confidentiality. It provides definitions and considerations for each topic as they relate to making ethical decisions and providing care to pediatric patients and their families from a variety of cultural backgrounds.

1. Ethical Issues in Child Health
Nursing
By
Mr. Ravi Rai Dangi
Assistant Professor
MSc. Child Health Nursing

2. Autonomy
• It refers to the freedom to choose & self determination in regard to
making health care decisions .
• Generally parents have the autonomy to make health care decisions for
their child . In certain situations older children have autonomy to give
assent to care& in special situations adolescents are granted a
autonomy to consent without parents knowledge.

3. Benefecience
• Refers to action that will benefit others .In Ped. Care this means actions of
kindness that will benefit the child rather than harming him or her.

4. Nonmaleficence
• Means avoiding causing harm intentionally or unintentionally.
• Justice : refers to acting fairly .Treatment decisions wil not be based on
factors such as age,gender,religion,socioeconomic status or ethnic group.

5. Veracity
• Is telling truth
• Fidelity : keeping promises& maintaining confidentiality & privacy
• Ped. Nurse should balance all these ethical components when dealing with
families from a variety of cultural & religious backgrounds while taking
decisions

6. Steps for ethical decisions
• Seven-step guide to ethical decision-making (Davis 1999)
• 1) State problem.
• For example, "there's something about this decision that makes me
uncomfortable" or "do I have a conflict of interest?".
• 2) Check facts.
• Many problems disappear upon closer examination of situation, while
others change radically

7. • 3) Identify relevant factors.
• For example, persons involved, laws, professional code, other practical
constraints ( e.g. under $200).
• 4) Develop list of options.
• Be imaginative, try to avoid "dilemma"; not "yes" or" no" but whom to go to,
what to say.
• 5) Test options.
• Use such tests as the following

8. Test options
• Use such tests as the following:
• harm test: Does this option do less harm than alternatives?
• publicity test: Would I want my choice of this option published in the
newspaper?
• defensibility test: Could I defend choice of option before congressional
committee or committee of peers?

9. • reversibility test: Would I still think choice of this option good if I were
adversely affected by it?
• colleague test: What do my colleagues say when I describe my problem
and suggest this option is my solution?
• professional test: What might my profession's governing body for ethics
committee say about this option?
• organization test: What does the company's ethics officer or legal counsel
say about this

10. • 6) Make a choice based on steps 1-5.
• 7) Review steps 1-6.
• What could you do to make it less likely that you would have to make such a decision
again?
• Are there any cautions you can take as an individual ( and announce your policy on
question, job change, etc.)?
• Is there any way to have more support next time?
• Is there any way to change the organization ( for example, suggest policy change at next
departmental meeting)?

11. Follow Bill of Rights -children
• To be called by name
• To receive compassionate health care in a careful ,prompt & courteous
manner
• To know the names of all care providers caring for the child
• To have basic needs met & usual schedules or routines honored

12. Rights cont..
• To make choices whenever possible
• To be kept NBM sos for shorter time possible
• To be unrestrained if able
• To have parents or imp. Persons with the child
• To have an interpretator for the child & family

13. Rights cont..
• To be educated honestly about the Child’s care
• To be respected as a person
• For all physicians to respect the child's confidentiality about his/her illness
always

14. Definition: Informed consent
• is a legal procedure to ensure that a patient, client, and research
participants are aware of all the potential risks and costs involved
in a treatment or procedure. The elements of informed consent
include informing the client of the nature of the treatment,
possible alternative treatments, and the potential risks and benefits
of the treatment.

15. • Parental consent should be odtained before any treatment or
participation in a research study for minors. If the minor is not in
the custody of either parents then consent is obtained from legal
guardian.

16. Consent -include
• Explanation of condition
• Description of alternative treatment or procedures
• A description of benefits to be expected
• An offer to answer the patient’s enquires
• Freedom from coercion , unfair persuasions or inducements.

17. Nsg. Considerations _in consent• Obtain informed consent from minor pt. as well as parents wherever
decision possible to avoid violating the right to self determination in
decision making .
• Encourage patient’s trust by representing the adolescent’s maturity.
• Refusal to acknowledge such maturity may be interpreted as a denial of
personhood

18. • Nurses must know the laws related to consent in the area of
practice.
• Avoid witnessing a telephonic consent & subsequent legal action
nurse may be viewed as closuring with the physician to elicit
permission from relevant patient & families. In such situations
suggest non professional person to witness the consent

19. Special considerations R/T informed consent
• Child not living with biological or adoptive parents
1. Legally appointed guardian must provide consent
2. Verify authority & include documentation of legally appointed guardian in
child’s medical record

20. Special issues contd..
• Parent consent after divorce
1. Determine if parents have joint custody or by one parent
2. Even parent with physical custody can give consent in emergency
3. Court involvement may be needed if there is joint custody but parents
disagree on care

21. • Consent for organ donation
1. Potential donors should be referred to local organ procurement
organisation
2. Educate family about policies related to organ donation
3. Legal guardian or parent consent to organ donation

22. • Consent for medical experimentation
1. Comply with all rules related to medical research in particular state & as
per the funding agency

23. • Parental refusal of medical treatment
May be due to cultural & religious beliefs e.g. Christian science ,pentecostal prefer
prayer or faith healing over allopathy treatment
Jehovah’s witnesses refuse blood product administration based on their religious beliefs
Hindus may refuse beef based foods & medicine
Islamic may refuse the use of any potentially addictive substances such as narcotics or
medicines containing alcohol

24. In some cases parents may refuse treatment if they perceive that their child’s
life may be significantaly impaired by the medical care which is offered.
• Nurse must be aware about the cultural & religious beliefs of the community
• Physicians must give adequate counseling to the parents in case of refusal

25. • Refusal of medical care is also considered as a form of child neglect. If
providing Rx may prevent substantial harm or suffering or save a child’s life
physician & Judicial sustem strive to advocate for the child .State authority
can order for proceeding the medical RX without parental consent this is
referred to as parens patriae

26. Assent
• Agreeing to something
• In Ped. Health it refers to the child’s participation in the decision making process about
health care (McCullough &Stein ,2009).
• Age for assent depends o the intellectual ,psychological & maturity level of child .As per
American Academy of Pediatrics child with an intellectual age of 7 yrs. Or older is
competent to understand participation in research & therefore provide an assent.

27. • While obtaining assent physician must help the child to understand his/her health condition
,depending on the child's developmental level.
• Inform the child of the RX planned & discussed what he or she should expect
• Determine what the child understands about the situation & make sure he or she is not
being unduly influenced to make a decision one way or another
• Acertain the child’s willingness to participate in the treatment or research
• Assent is a process & should contotinue throughout the course of treatment or research
protocol

28. Disent
• Disagreeing with Rx plan
If the child of 13 to 17 yrs of age disagrees the Rx then it becomes a binding
for physician to accept it
But in case of significant morbidity & mortality this can be overridden. These
cases are considered on ind. basis. If decision is made to move forward with
RX despite the chil

29. Advance directives
• It determines the child’s & family’s wishes towards initiation or discontinuation of life
saving measures such as antibiotics ,dialysis . Ventilatory support , CPR artificial nutrition &
hydration .
• DNR or AND (allow natural death ) order is placed as per the consent given by parents.
Insructions should be followed as per the state & institutional policy

30. Confidentiality issues
• Very imp. Do not leave patient information visible on computer or file
• Do not discuss the case or share information to the lay people