An Ethical Claim for Providing Medical Recommendations in Pediatric Intensive Care

The Declaration of Geneva was recently revised to emphasize patient autonomy and the importance of clinicians sharing medical knowledge. This reflects the welcome evolution of the doctor-patient relationship from one of paternalism to more informed, shared decision-making. Unfortunately, there is an increasing trend for clinicians to avoid making recommendations, instead providing a “menu” of care options from which patients and families must choose. This seems to be underpinned by the belief that it is unacceptably paternalistic to give guidance as to which course of action may be best to take. In this article, we argue that there is an ethical imperative for doctors to provide medical recommendations. This is discussed with particular emphasis on the pediatric critical care setting, where autonomy and shared decision-making are especially complex. We outline how a failure to provide clinical recommendations represents inadequate shared decision-making and erodes the doctor-patient relationship, leading to suboptimal care, paradoxically decreasing respect for autonomy. We describe an approach through which doctors can avoid paternalism without placing an undue burden of decision-making on families. We assert that patients’ interests are best served by clinicians taking an active, relational role in shared decision-making, including exploration of values and giving explicit medical recommendations for care. This research was performed at the Boston Children’s Hospital, Boston, MA. Dr. Alexander’s institution received funding from Novartis and Tenax Therapeutics (provide levosimendan to his institution as part of an Expanded Access Study). The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Katie Moynihan, MBBS, FCICM, FRACP, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Av, Boston MA 02115. E-mail: Katie.Moynihan@cardio.chboston.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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