Leon Kass, the physician-philospher, stated that the physician's duty is to serve the patient's good. ' Different views exist, however, as to what constitutes the patient's good. Consequently, any attempt to determine how the pediatrician should respond will depend on individual beliefs. The difficulties inherent in defining the patient's good can best be understood by examining the two models of moral responsibility in medicine as described by Beauchamp and McCullough2: beneficence and autonomy.
According to the description of the beneficence model, the physician is expected to seek good and avoid harm as medicine understands them: the major good is health; the major harm is illness. For health to be obtained, disease or injury must be prevented or eliminated. Additional good perceived by medicine is relief from unnecessary pain and suffering, amelioration of handicapping conditions, and prolongation of life.
In clinical situations, the beneficence model requires that the physician constantly weigh the good of medical intervention against the risks of harm presented by not only disease and handicaps but also medical interventions themselves. In addition, the physician must balance benefits against harm, benefits alternative benefits, and harm against alternative harm. These determinations require that the maintain the professional skills required to properly weigh and balance the alternatives. If the physician's determination differs from that of the patient, the beneficence model dictates simply that the physician act in accordance with the ends of medicine. Thus, the model frames the physician's in terms of medically specific ways of providing benefits and avoiding harm.
In contrast to the beneficence model, the autonomy model takes the values and beliefs of the patient (or, in pediatric practice involving young children, the parent) to be the moral consideration in determining the physician's responsibilities in patient care. If the patient's values directly conflict with those of medicine, the central responsibility of the physician is to respect and foster a patient's self-determination in making medical decisions. The obligations and virtues of the physician thus flow from the principle of respect for autonomy.
Four-year-old Nellie Brown is brought to the pediatrician's office by her parents because of a fever of 24hour duration. Her father tells the doctor that he was up all night with his daughter. While the pediatrician is taking the child's history and examining her, the father is impatient and brusque with both his daughter and wife. The physician attributes this behavior to lack of sleep.
The child's physical examination reveals a rectal temperature of 1020F, a reddened pharynx and tonsils, and slightly enlarged cervical lymph nodes. There are no other abnormal findings. After taking a throat culture, the pediatrician tells the parents that the child has a viral throat infection that will resolve spontaneously.
Before the pediatrician can continue, the father interrupts and angrily demands an antibiotic be prescribed. The physician knows that the infection is selflimited, that antibiotics are not beneficial in this situation, and that their indiscriminate use is contrary to good pediatric practice. In view of the father's demands, however, some pediatricians might prescribe the antibiotic to save an explanation and to pacify the parents. The ethical predicament in this instance, therefore, is whether or not it is "right" for the pediatrician to prescribe an antibiotic for Nellie. 3
To fully explore this dilemma, an understanding of the moral nature of pediatrics is needed. The author offers the following: the ethos of pediatrics is to seek the emotional and physical health of the child within the family unit by working with the parents. In this joint venture, the parents give their permission to the pediatrician to perform certain interventions in the child's behalf. In addition, the parents are available to receive advice and instruction from the doctor for the proper care of their child. Thus, pediatricians are instructors and counselors to parents as well as providers of medical care to children.
In the case of Nellie Brown, the pediatrician believes that an antibiotic would offer no clear-cut medical benefit to the patient. The diagnosis could, however, be wrong; if so, Nellie may actually be cured by an antibiotic. But the probability of a misdiagnosis is low. Moreover, administering the antibiotic may have some harmful effects: Nellie could develop an allergic or toxic reaction or become sensitized to the drug and suffer an allergic reaction upon a subsequent exposure. Although not likely, the drug may aid in the natural selection of new strains of bacteria that are resistant to it. Finally, the parents will incur unnecessary expense in paying for the antibiotic.
Prescribing the requested antibiotic will satisfy the father, at least temporarily. However, if it is prescribed, there may be other untoward consequences beside those that might involve Nellie's health. First, the father's erroneous notion about the proper use of the medication will be reinforced. Second, the parents will expect the pediatrician to prescribe a drug each time their child has a fever and may become dissatisfied if one is not administered. It is also possible that the parents may eventually become annoyed at the pediatrician if a drug is prescribed and they learn later that antibiotics are not indicated for viral disease.
Refusing to prescribe the antibiotic, despite the father's insistence, also has cerrain consequences. It is likely that the father will become angry enough to take his child elsewhere for treatment. This action might deprive the child of appropriate follow-up care and it will also deprive the initial pediatrician of future income.
Ideally, the pediatrician as health educator should have explained to Nellie's parents, prior to this illness and at a more tranquil time, that it is not routine to prescribe an antibiotic for fever alone or when the diagnosis is a viral infection. Since this is the first time that the doctor has met Nellie's father, it is possible that Mrs. Brown was informed about this practice at a previous well-child visit, but that she has not shared this information with her husband.
If the pediatrician holds strongly to the autonomy model of moral responsibility, a prescription may be provided with no comment about its indications or contraindications. This action will, however, deny the pediatrician the opportunity to educate and will deny the parents important instruction. Furthermore, since the pediatrician believes that an antibiotic is not indicated in this situation, prescribing the drug without comment may be demeaning.
One strategy would be for the pediatrician to tell the parents of a policy of not using an antibiotic in such cases and to explain why; offer the option of instructing them about other medications that may be prescribed; and reassure them that an antibiotic will be prescribed if the throat culture indicates a streptococcal infection. This strategy would allow the physician to maintain an educator role, yet give the parents some control over the situation.
When the father has already requested a prescription for the antibiotic, however, the pediatrician may realize that it is not a propitious moment for imparting information let alone providing instruction. If the father insists on the prescription a crisis could ensue and, as mentioned above, the parents could seek medical care elsewhere.
The pediatrician who adheres strongly to the beneficence model and believes an antibiotic offers no benefit would be willing to accept such an outcome. Although the medical profession does not have any privileged status, Brett and McCuI lough4 contend that
it does have status as a group to which society entrusts certain responsibilities regarding the health of its members. Our society implicitly acknowledges that the medical profession has a body of knowledge and an expertise that allows it to promote a social and personal good (ie, health). When physicians are obligated to act in directions contrary to their professed purpose, the profession cannot be expected to function in its intended manner. If the "aim of medicine should be seen as a form of beneficence," as Thomasma5 has stated, then doing harm in the service of autonomy is illogical.
Beside being consistent with the beneficence model, in informing the father that antibiotics are not required in illnesses such as Nellie's the pediatrician is attempting to perform the role of educator and counselor.
However, other aspects of this case need to be considered. Although one of the norms of medical practice is that only scientifically validated therapies be offered to patients when such are available, Levine6 is concerned about doctor-patient relationships. To encourage such relationships, he proposes that "conversations" be designed to reduce tensions between the involved persons, rather than between competing ethical considerations such as beneficence and autonomy. To do otherwise, Levine believes, is to apply an "ethics of strangers" rather than an "ethics of responsibility. "
Furthermore, he argues,
As a consequence of being attentive to the needs of particular patients with whom they form attachments in particular contexts, [doctors] may reach agreements to take actions which may be unsuitable for patients in general.
Thus, he suggests that the "rules" may be bent or suspended in some cases to preserve relationships with particular patients. The pediatrician who takes Levine's advice seriously has the option of embarking upon a conversation with the parents that offers a short- term concession. Before proceeding with such a conversation, the pediatrician should have a genuine interest in retaining an ongoing relationship with this family and have good reason to believe that the father, if given some reasonable control over the immediate situation, is educable in the long run. If these conditions are met, the pediatrician can consent to prescribing the antibiotic on this one occasion, provided that the father understands the risks and agrees that it will not be requested or prescribed routinely in the future.
Some may believe it is contradictory to tell these parents that the antibiotic is not medically indicated and to prescribe it anyway; nonetheless, such an approach can be justified. First, the antibiotic is going to be prescribed only once. Second, and more important, the argument for acquiescing to the parents request concerns the anticipation of benefit. Brett and McCullough state that for the patient's anticipation of benefit to be definitive in decision making, "there must be at least a modicum of potential benefit as seen from the medical perspective," even if the physician and the patient are in general agreement about the magnitude or risk of harm and the patient assigns more benefit to the intervention than does the physician. Although no medical benefit is identified in the immediate situation, the concession could result in a social benefit, ie, retaining and strengthening of an ongoing relationship with this family. Moreover, as Beauchamp and McCullough have asserted, "the [beneficence] model has no power to show that the physician's medical judgment must always override the patient's. The model simply frames the physician's obligations in terms of medically specific ways of providing benefits and avoiding harms." Obviously, in this instance, there are risks to the pediatrician, but such an attempt may ultimately help maintain an arrangement that could be the best for Nellie, the parents, and the pediatrician.
In striving to provide quality medical care to the child and in serving as an educator and counselor to the family, the pediatrician can pursue several different decision making paths. The chosen path will depend on the pediatrician's medical knowledge and skill, but will also be influenced significantly by views of moral responsibility in medicine and attention to the emotional and social factors in the physician-patient encounter.
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3. Brinjv H: Ethical Decisions m MeuVme. Boston. Litrle. Brown & Co. 1981.
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