All practicing pediatricians, in the course of years, meet numerous problems that test their ethical judgment and convictions. How they react may be largely due to their upbringing, their religious beliefs, their medical background, their legal considerations, and their empathy.
I turn to the readers of this column to present three such situations I faced and to ask if they agree or disagree with my attitude and conclusions.
The first is a situation 1 related in Pediatric Annals six or seven years ago. One of my early internships was in Pediatric Surgery at St. Mary's Hospital for Children located on the southern border of Hell's Kitchen - a poor and notorious area in New York City. The hospital, a teaching unit of Cornell University Medical College, was run and supervised by Sisters of the High Episcopal Church.
One day a badly deformed female newborn was brought to the hospital. She had a hare lip and cleft palate, a right eye socket lacking an eye, a tiny lump of flesh instead of a right ear, and a stump for the right arm and right leg. The infant was the sixth child of a poor family living in Hell's Kitchen. There were numerous consultations the first few days among the surgeons, the orthopedists, the ophthalmologists, and a representative of a new group - the plastic surgeons.
When the infant was six days old she developed a severe diarrhea with dehydration. Should we save this terribly disfigured infant? The odds were all against her. So I went to Sister Catharine, the elderly, gentle Sister Superior of the hospital. "Sister," I said, "This terribly deformed baby girl is surely doomed to a life of unhappiness, numerous painful operations, at the best a poor end result with no chance of being attractive, and to living in a desperately poor, underprivileged family. Now the baby has severe diarrhea and dehydration. I believe this may be God's way of taking this unfortunate infant out of this world. Will you permit me to not treat this child vigorously.'"
The elderly sister stiffened up in her chair behind her desk, gave me a cold stare for a moment and then almost shouted, "Dr. Levine, who do you think you are - God?" So we treated the infant vigorously and she recovered - and continued toward her pathetic future. Was I right or was I wrong?
The second ethical problem that comes to mind involved a girl I had followed from birth. She was new 18 years of age and through the years had grown to look on me as her protector and confidant. One day she came to me, told me of her deep love affair, that she was going to have sexual relations, and asked if I would provide her with contraceptive pills. She could not tell her parents. I talked to her at length and finally prescribed the pills. Gloria hugged and kissed me and left the office.
Two weeks later I received a telephone call from an infuriated father. His wife had found the pills on their daughter's dresser. How dare I prescribe birth control pills without their knowledge or consent? 1 tried to explain to him that I was anxious to prevent their daughter from having an unwanted pregnancy. There was too much tragedy associated with such a happening.
One year later the girl married this same young man and a year after that they brought their newborn baby in for routine child care. Was I right or was I wrong by prescribing the pills?
The third memory I have selected to discuss, one of numerous ethical problems, is another adolescent situation. I had for some years been the pediatric commentator on a national television program and had discussed many problems including child adoption. One day I had a long distance telephone call from a mother who had heard my program. Her 16-year-old daughter, a college freshman, was selected as the queen of the annual football "Bowl" game. She met the captain of her winning college team, formed a relationship, and became pregnant.
Her parents, from a well known and well established southern family, were frantic and planned to keep the pregnancy a secret. They decided to send their daughter to a "private school" in New York City for six months "for special studies." The mother asked if I could arrange for expert obstetrical care and for the baby to be taken at birth to an adoption agency. I told her I would be happy to make these arrangements.
The girl arrived at my office one week later. She was unusually beautiful. She was in her fourth month of pregnancy. I referred her to a leading obstetrician whom I informed of the situation. I made arrangements with the adoption agency. I had her enroll to take courses at a college in New York City where credit could be accepted at her school.
Everything went smoothly. The girl had her baby, which was given over to the adoption agency, and she returned to her home, friends, and school. A few years later I had another long distance call, this time from the young girl. She was engaged and planning to be married shortly. Did she have to tell her fiance about the pregnancy? I told her, "By no means. Only unnecessary trouble can result. Live happily and don't worry. The walls of the adoption agency are impenetrable." Was I right or was I wrong?
This present issue of Pediatric Annals is devoted to the subject of ethics in pediatrics. It is under the Guest Editorship of Dr. Tomas J. Silber, Associate Professe ? of Child Health and Development, George Washington University School of Medicine, and Director of the Department of Adolescent and Young Adult Medicine at the Children's Hospital National Medical Center, Washington, FJC. Dr. Silber has chosen to present in this symposium examples of some of the most controversial subjects under discussion at the present time. Among these are arguments concerning abortion, child adoption, and organ transplantation.
The first paper on "Ethical and Legal Issues Relating to Abortion in Adolescence" has been written by Dr. Silber. Most of us who practiced pediatrics before abortions were legalized remember clearly the many tragic situations occurring in adolescent girls who underwent illegal abortions or attempted to miscarry or perform se If- abort ions. In those days it was difficult to find a well trained, capable gynecologist willing to risk his license by performing illegal procedures.
Today, with the legalization of abortions, new discussions, primarily social and religious, have arisen. Dr. Silber in his article discusses all aspects of the problems and notes that the Academy of Sciences Panel on Adolescent Pregnancy and Childbearing called for aggressive pediatric education, the widespread availability of oral contraceptives and condoms, and the need for sex education programs.
The second article deals with a recent concept - "The Adopted Adolescent and the Birth Parent Quest. " It has been contributed by Dr. Adele D. Hofmann, Clinical Professor of Pediatrics at the University of California, Irvine. It is co-authored by Dr. Hofmann's adopted daughter, Annie Gardiner, BA, who successfully found her biological mother. This new concept of establishing one's true identity has in many cases been highly successful. I was for years a member of the Executive Board of one of the largest adoption agencies in New York City. At that time our effort was to make adopted children look to their adopted parents as their real parents who wanted them, loved them, and took pride in their development. Therefore, adoption agencies concealed the identities of the biological parents.
In recent years, it has been recognized that a great many adopted children have a deep desire to find and meet with their biological parents. I have personally known of four of these reunions and they ended amicably, except for one case where the adoptive parents reacted angrily and disinherited their now married daughter. Today many adoption agencies will agree to a reunion only if the biological mother consents.
The third contribution to this symposium discusses "Organ Transplantation in Adolescents: Moral Issues." It is presented by John C. Moskop, Associate Professor of Medical Humanities of the East Carolina University School of Medicine, Greenville, NC. Although renal transplantation has for years been carried out successfully, it is only within recent years that the transplants of heart, lungs, and liver have increased due largely to the use of cyclosporin. However, as Dr. Moskop relates, there are situations where the advantages of transplantation are questionable.
The remaining articles in the symposium discuss parents who refuse needed treatment for their child's illness and the pediatrician's role. What are the rights of the parents versus the rights of the child to assent to treatment? How should we handle the parents who demand medical treatment for a child when the physician feels it is con tra indicated?
This is an interesting issue of Pediatric Annals that discusses many of the ethical and moral issues so often faced in the practice of pediatrics.