ETHICS/PAIN MANAGEMENT
| ETHICAL DILEMMAS IN ADOLESCENT HEALTH CARE —Christopher V. Chambers, MD, Professor and Fellowship
Director, Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia,
PA
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| Ethics and law: different issues (laws based on ethics, however, some ethical decisions at odds with law); concern about
giving adolescents decision-making capacity; paternalism subsumed under beneficence
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| Mainstays of ethical decision-making: beneficence—“do the right thing”; autonomy—competent person who
can understand risks and benefits of treatment offered should make decisions for himself or herself; societal requirements
about minimum age create problems; nonmaleficence—primum non nocere (“first do no harm”), but, if only consideration
in decision-making, decision often wrong; justice—doing right thing for most people and providing greatest benefit;
additional issues—include truth-telling
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| Informed consent: case—14-yr-old boy presents in office alone and requests physical examination; should physician
see him?
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 | Regulation: usually, state laws govern how medical systems interact with teenagers
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| Age of consent (criteria in Pennsylvania): ≥18 yr of age (legal age of majority); married; pregnant (or previously pregnant)
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| Emancipated minor: legal term (some variation, depending on state); in general, someone living away from parents;
examples—runaway or “throwaway” teenagers (if physician judges teenager has capacity to make decisions concerning
own medical care); married individuals; military personnel
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| Doctrine of mature minor: enables minors to give consent to medical procedures if they can demonstrate sufficient maturity
to make decisions on their own; derives from Supreme Court decision that recognized that 18-yr-of-age restriction
somewhat arbitrary; suggests that younger patients (eg, ≥14 or 15 yr of age) can make decisions in their own best interest;
note—treatment must not involve high-risk procedures (eg, donating kidney)
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| Pregnancy: case—14-yr-old girl pregnant; what is physician’s responsibility to this patient?
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| Parent-child relationship (historical perspective): in early colonial America, total parental sovereignty (parents had absolute
autonomy); with industrialization, child welfare laws limited working hours of children, but centrality of family
unit remained; in 1967 case, 15-yr-old boy made obscene phone calls and remanded to juvenile justice system without
due process; Supreme Court ruled that minors had same rights to due process as adults; during Vietnam war era, free
speech rights affirmed; in 1973, abortion rights extended to adolescents
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| Adolescents’ options: all states—by law, pregnant teenager can give informed consent about her own health care; she
may continue pregnancy and receive obstetric care without involvement of parents (physician’s goals include uniting
families and improving communication); terminating pregnancy—Pennsylvania and Delaware have parental notification
laws and require 24-hr delays; in Delaware, notification may be given to parent, grandparent, or legal guardian;
exceptions—patient at risk for physical retribution by family; judicial “bypass” available if, in physician’s judgment,
unfair to require parental or other notification (eg, history of abuse by parents); in some states, parental consent not
necessary to terminate pregnancy (but illegal to help person cross state borders to terminate pregnancy)
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| Physician referral: study by Orr (1984) used hypothetical case of 15-yr-old patient seeking contraceptive services; large
number of family physicians and pediatricians would not provide contraceptive services, but would refer elsewhere
(small percentage of teenagers carry out referral)
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| Abnormal cervical cytology: case—parents of 16-yr-old girl have already given permission for her to receive reproductive
health care without their involvement; patient has high-grade squamous intraepithelial lesion [HSIL]), but has
not followed up or responded to numerous phone calls from office; how should physician proceed? does this patient
have right to decline care?
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| Guidelines: in some states, treatments for which adolescents may give consent include pregnancy care and evaluation and
treatment of sexually transmitted infections (STIs); institutional review board (IRB) principles—guiding principle,
respect for person (autonomy); for participation in research, person must understand all circumstances of his or her involvement
in study and risks and benefits of participation; beneficence (paternalism); justice
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| Speaker’s approach: inform girl about plans to involve her family due to concern about possibility of cancer
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| Suicidal ideation: case—16-yr-old boy previously assured confidentiality; patient reports contemplation of suicide;
boy and parents have same physician
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| Criteria for “justified paternalism”: imminent physical harm likely; intrusion probably will protect person from harm;
person likely to say “thank you” at later time; intrusion generalizable (group looking at situation would reach same
conclusion)
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| Portable illness: eg, certain STIs and tuberculosis; right to consent to care does not equal right to informational privacy;
protecting privacy assumes that patient will take responsibility for identifying and notifying partners; public health authorities
require physician to submit information and to monitor occurrence of appropriate follow-up; operant ethical
principle, justice (also, beneficence)
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| Sterilization: case—16-yr-old girl, moderately-to-severely retarded; she spends weekdays in institutional care, but
sleeps at home and comes home for weekends; she has job folding boxes; although severely cognitively impaired, patient
very affectionate; parents worried about her possibly becoming pregnant and request permanent sterilization;
what should physician do?
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| Changes in societal attitude: in 1907, first state statute authorizing involuntary sterilization enacted in Indiana (era of eugenic
sterilizations began); in 1930s, most states had sterilization statutes; in 1945, world learned of forced sterilization
in Nazi Germany and public criticism of involuntary sterilizations increased; during 1960s, civil rights movement enhanced
reproductive rights; in 1970s, almost all states repealed laws enabling involuntary sterilization
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| Parental attitudes (study by Passer): 85% of 69 parents of retarded daughters favored legislation enabling sterilization under
certain circumstances; other options—effective birth control available short of permanent sterilization
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| Protocol at speaker’s institution: convene ethics committee and appoint advocate for mentally retarded or cognitively impaired
girl (and often another advocate for family); involve physicians and legal counsel in resolution; intervention—
in most instances, permanent sterilization not performed
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| Adolescent health research: case—investigator would like to interview teenagers about effects of childhood sexual
abuse on intimacy and ability to form meaningful relationships; requiring parental permission for participation would skew
results; reasonable to ask IRB for waiver of parental permission?
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| IRB waiver of parental permission for adolescent health research
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| Qualifying scenarios
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| 1) Research not involving greater than minimal risk
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| 2) Greater than minimal risk, but includes prospect of direct benefit to subjects
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| 3) Greater than minimal risk, no prospect of direct benefit to individual, but likely to yield generalizable knowledge
about subject’s disorder or condition
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| Additional guidelines:
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| 1) Investigator ensures privacy and confidentiality
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| 2) Appropriate informed consent obtained from each participant
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| 3) Noninvolved adult serves as advocate (no formal legal role)
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| 4) Appropriately trained professional (eg, psychologist) consulted to confirm cognitive ability and reasonable judgment
about risks and benefits of participation, and to assure personal responsibility among subjects
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| Summary of principles governing adolescents’ rights to health care: courts appropriately reluctant to contravene
parental rights; in certain situations, minors better served if parental consent not required; minor’s rights to self-consent
for contraceptive care constitutionally derived; physician’s responsibility to pregnant teenager more complex (onus on physician
to help teenager make best decision); right to consent to treatment does not necessarily include right to informational
privacy
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| PAIN IN PEDIATRICS— Elizabeth T. Drum, MD, Associate Professor of Anesthesiology and Pediatrics, Temple University
School of Medicine, Philadelphia, PA
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| Pain: definitions—unpleasant sensory and emotional experience associated with actual or potential tissue damage; sensory/emotional
experience that results from stimulation of nerve fibers; why does pain exist?—to protect individual
from actual or perceived tissue damage; how do we experience or react to pain?—depends on type of pain and previous
experiences with pain; expression of and reaction to pain often complex; subjectivity—difficult to answer above
questions without considering emotional component; age, developmental level and previous experiences influence perception
and expression of pain
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| Historical perspectives: although early philosophic and scientific writings discussed importance of pain in infants and
children, paradigm shift in late 19th century declared that neonates and infants incapable of fully experiencing pain; research
later revealed that unmyelinated fibers do conduct pain; study by Anand (1987)—density of nociceptors in skin
greater in neonates than in adults; cutaneous sensory receptors complete by 20 wk gestation (pain pathways to brain stem
and thalamus well developed by 30 wk); newborns have anatomic and functional components necessary for perception of
painful stimuli (even if less developed than in adults); behavior indication of cortical function; density of substance P
(neurotransmitter involved in perception of pain) higher in neonates than in adults; postulated that untreated acute pain
increases mortality in neonatal surgery without anesthesia
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| Physiologic consequences of pain: increased catecholamines, oxygen consumption, myocardial ischemia, and lactic
acid; hyperglycemia; release of antidiuretic hormone and cortisol; inflammation with increased vascular permeability; increased
plasma cytokines; same physiologic mechanisms exist in children, but less attention paid to physiologic consequences
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| Assessment of pain: multiple assessment tools, including 1-to-10 scales; experience of pain includes subjective and
emotional component; children cannot always report or describe pain (depends on age and developmental status); most
institutions have multiple scales to measure pain; examples—Wong-Baker FACES Pain Rating Scale; Face, Legs, Activity,
Cry and Consolability (FLACC) pain assessment tool (gives score based on facial expression, limb movement, and
whether patient crying or sleeping; results indicate mild, moderate, or severe pain)
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| Types of pain: acute—result of injury or acute process, typically responds to directed therapy with predictable course
of recovery; vague—may require evaluation to rule out severe disease; chronic—may occur with cancer or other
chronic disease (eg, sickle cell disease or severe rheumatologic process)
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| Treatment of pain: depends on type of pain and perception of pain by patient; important to understand age, developmental
needs, and background of patient in order to individualize approach
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| Pharmacologic treatment: traditional opioids and nonsteroidal medications; agonist-antagonist drugs (eg, naloxone);
α2 -agonists (eg, clonidine); local anesthetics; delivery systems—oral delivery preferred in outpatient settings; intravenous;
topical; neuraxial (spinal or epidural) or nerve blocks; intranasal or transcutaneous; patches and dissolving oral tablets
for cancer pain
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| Addiction and tolerance: issue in neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU; patients
treated for chronic pain or treated for long period after severe illness), and in patients receiving extracorporeal membrane
oxygenation; strategies available to evaluate development of addiction and tolerance, and to prevent and treat; once treatment
initiated, goal to transition from opioids to nonopioid drugs; because of physiologic consequences of untreated pain,
fear of addiction no reason to withhold treatment; if tolerance develops, well described strategies slowly decrease need
for opioids
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| Chronic pain: continuous or recurrent pain lasting ≥3 mo; prevalence varies, depending on age and sex; children with
frequent complaints of aches and pains use more health care services, have more psychosocial problems, miss more
school, and perform worse academically
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| Treatment of chronic pain: some evidence from adult literature on efficacy of antidepressants and anticonvulsants in
minimizing perception of pain; use of regional anesthesia and blocks helpful in breaking cycle of, eg, chronic limb pain
resulting from injury; usually involves pharmacologic and nonpharmacologic interventions
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| Areas of study: age at development of pain (relevant to fetal surgery); variability in perception of pain; effects of
chronic or undertreated pain; neural mechanisms; pharmacologic interventions; economic impact
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Educational Objectives
| The goal of this program is to educate the listener about ethical dilemmas in health care and about pain management. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Describe the relationship between law and ethics.
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| 2. Outline principles of ethical decision-making.
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| 3. Apply ethical principles to areas of controversy in the medical treatment of adolescent patients.
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| 4. Assess pain in infants and children.
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| 5. Treat pain in infants and children.
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Discussed on This Program
Clonidine HCl [Catapres, Duraclon]
Naloxone HCl [Narcan]
Suggested Reading
Anand KJS, Hickey PR: Pain and its effects in the human neonate and fetus. N Engl J Med 317:1321, 1987; Bachiocco
V et al: A pain educational program for pediatric nurses: topics and key points. Pediatr Med Chir 27:34, 2005;
Banister E: Considerations for research ethics boards in evaluating qualitative studies: lessons from an ethnographic
study with adolescent females. Ann R Coll Physicians Surg Can 35:567, 2002; Brisbon N, Chambers CV: Neurocognitive
development in adolescent males, or adolescent boys are from Pluto. Prim Care 33:223, 2006; Bursch B et
al: Preliminary validation of a self-efficacy scale for child functioning despite chronic pain (child and parent versions)
Pain 125:35, 2006; Chamberlain A et al: Issues in fertility control for mentally retarded female adolescents: I. Sexual
activity, sexual abuse, and contraception. Pediatrics 73:445, 1984; Drendel AL et al: Pain assessment for pediatric patients
in the emergency department. Pediatrics 117:1511, 2006; Lothen-Kline C et al: Truth and consequences: ethics,
confidentiality, and disclosure in adolescent longitudinal prevention research. J Adolesc Health 33:385, 2003; Madhok
M, Teele M: Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric
emergency department. Pediatrics 118:1321, 2006; Metvier H, Hasson SM: Use of the faces pain scale to evaluate
pain of a pediatric patient with pauciarticular juvenile rheumatoid arthritis. Physiother Theory Pract 22:91, 2006; Orr
MT, Forrest JD: The availability of reproductive health services from US private physicians. Fam Plann Perspect
17:63, 1985; Passer A et al: Issues in fertility control for mentally retarded female adolescents: II. Parental attitudes toward
sterilization, Pediatrics 73:451, 1984; Phillips SR: Asking the sensitive question: the ethics of survey research and
teen sex. IRB 16:1, 1994; Ratcliff SL et al: The effectiveness of a pain and anxiety protocol to treat the acute pediatric
burn patient. Burns 32:554, 2006; Rogers AS: The Society for Adolescent Medicine’s Code of Research Ethics. J Adolesc
Health 24:283, 1999; Sinha M et al: Evaluation of nonpharmacologic methods of pain and anxiety management for
laceration repair in the pediatric emergency department. Pediatrics 117:1162, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Dr. Chambers was recorded at Ethical Issues in Pediatrics, presented October 4, 2006, in Wilmington, DE, by Nemours,
Alfred I. duPont Hospital for Children, and Nemours Children’s Clinic; Dr. Drum was recorded at the Twenty-Sixth Annual
Pediatric Novemberfest, presented November 9-10, 2006, in Atlantic City, NJ, by Temple University School of Medicine.
The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this
program.
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