Ethical Dilemmas in Pediatric Healthcare - Case Studies

HCR 210 - Pediatrics Case Studies Case 1: Steven was a 17-year-old male who presented to the clinic with complaints of a broken arm. During the visit, the clinician noted that Steven was very quiet, and his mother would answer all of the clinician’s questions for him. It was revealed that his arm was broken two weeks ago while when he fell during a basketball game. They did not seek medical care at that time since he was feeling fine, but the pain has gotten progressively worse and has been interfering with his ability to help with chores at home. The clinician was concerned after hearing this story and asked Steven’s mother to step out of the room. During the one-on-one conversation with Steven, he revealed that his mother broke his arm while she was intoxicated. Upon further questioning, Steven stated that his mother had been having a hard time dealing with the loss of her husband (Steven’s dad) two years ago. She has been drinking every other night and sometimes loses control of her temper when intoxicated. She never meant to hurt Steven, but accidents sometimes happen. Steven seemed embarrassed and nervous when explaining what happened to him. The clinician mentioned contacting the state Child Protection Services (CPS), but this made Steven more upset. He stated that he only wanted to get his arm fixed; he did not want to get his mom in trouble and he absolutely does not want to be taken away from his mom. He regretted sharing this information at all, and he would prefer if the clinician just left him alone. Case 2: Kathy was a 10-year-old female who presented to the emergency department 2 days after an appendectomy. Kathy was unconscious, hypotensive, and a CBC demonstrated acute anemia (RBC 5.0). The surgeon wanted to perform an emergency explorative laparotomy to see if something went wrong at the surgical site. However, the surgeon stated that Kathy would need a blood transfusion prior to surgery, otherwise there would be a high risk of mortality. Kathy was a Jehovah's Witness, and her parents refused to accept a blood transfusion. The surgeon declared that without a blood transfusion, Kathy’s condition will get worse and she will die. The parents continued to refuse and stated that they would prefer that their daughter “died and went to heaven” than risk violating their religious beliefs. The healthcare was unable to confirm Kathy’s religious beliefs or ask her what she would want since she continued to be nonresponsive. Case 3: E.G. is a 17-year-old Jehovah's Witness from Illinois who is diagnosed with acute non-lymphatic leukemia. The treatment of this disease would involve receiving chemotherapy and blood products, without which E.G. has a very grim prognosis. While E.G. and her mother consent to medical care for chemotherapy, they both refuse to accept blood products since it would violate their personal religious beliefs. They sign a waiver with the clinicians to absolve them of medical liability for failure to administer blood transfusions. Another physician in brought in to evaluate the patient. It is noted that without a blood transfusion, E.G. would likely die within 1 month’s time. With treatment, E.G. would likely have an 80% chance of remission but the overall long-term prognosis is only 20-25% chance of survival after 5 years. E.G. is noted as being mature for her age, and she understands the severity of her illness including the very real likelihood of death. However, she continues to fight for her religious beliefs and stands by her decision to refuse blood products. Case 4: Daniel Hauser was a 13-year-old boy from Minnesota who was diagnosed with stage IIB nodular sclerosing Hodgkin disease. Doctors predicted that this form of cancer would be highly treatable with a 80-95% chance of complete remission with 5 years of treatment. Daniel was prescribed 6 cycles of chemotherapy followed by radiation therapy. His parents had initially consented to this treatment plan, but they changed their decision after one round of chemotherapy due to the side effects of nausea and fatigue that Daniel experienced. The Hauser’s sought out opinions from several different pediatric oncologists, all of whom strongly agreed that the only treatment for Daniel was to complete chemotherapy and radiation therapy. Without treatment, Daniel had a bleak chance of survival. The Hausers and Daniel continued to refuse treatment chemotherapy in favor of alternative therapies such as dietary changes and ionized water to “starve the cancer” from his body. They justified refusal of treatment by claiming that it would violate their religious beliefs. The family was not of Native American descent, but they identified with the Native American religious organization, Nemenhah, which places a strong belief in Native American Holistic medications and the basic tennet of “do no harm.” Daniel’s mom expresses the belief that God intends for the body to be healed in the natural way, she and views chemotherapy as a self-destructive and poisonous harm. Daniel agrees with his mom and states that chemotherapy would violate this wishes, his religion, and his status as a Medicine Man in Nemenhah tradition. Daniel does not belief that he is sick or that he has life-threatening cancer since he generally feels well when he is not undergoing chemotherapy.