Pediatric ethical conflicts increasingly confusing
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* Charlotte Gray

If patients are not competent enough to make health care decisions, what principles should govern the decision-making of their health care professionals, especially when life-and-death issues are involved?

Anyone working in pediatrics is acutely aware of the conflicts involved in these cases. Dr. Christine Harrison, director of bioethics at Toronto's Hospital for Sick Children, told the recent meeting of the Canadian Association of Paediatric Hospitals that "such cases are not unusual in our system. But they are receiving a lot of media attention because of particular pressures in contemporary Canada."

In Canada's pluralistic society, cultural practices are often in conflict with the imperatives of evidence-based medicine. Moreover, as pediatric institutions shift to an emphasis on "family-centred care," professionals and parents must establish a partner-partner relationship rather than an expert-client one.

As well, more and more Canadians are turning to alternative therapies: 75% of the families bringing children to Sick Kids are also using alternative treatments such as herbal medicines. In the case of Tyrell Dueck, a 13-year-old Alberta cancer patient, health authorities had to back off and watch Dueck's parents waste $65 000 (of which they have raised only $45 000) on a trip to a Mexican clinic for an unlicensed, unproven therapy.

"What mechanisms are required within institutions to turn conflicts into consensus?" asked Harrison, who acknowledged that these cases never involve "win-win" solutions. When it appeared possible that the courts would order the health care team to impose treatment on Tyrell Dueck, hospital staff faced the horrifying prospect of forcing the child to undergo surgery. (His cancer proved too far advanced for surgery, and he died last summer.)

In Canada, the Bioethics Committee of the Canadian Paediatric Society has already articulated the principles on which decisions about the withdrawal of treatment for critically ill children should be based (*CMAJ* 1986;135[5]:447-8).