Guedert and Grosseman BMC Medical Ethics 2012, 13:2

[Link]

RESEARCH ARTICLE Open Access

Ethical problems in pediatrics: what does the

setting of care and education show us?
Jucélia Maria Guedert*† and Suely Grosseman†

Abstract
Background: Pediatrics ethics education should enhance medical students’ skills to deal with ethical problems that
may arise in the different settings of care. This study aimed to analyze the ethical problems experienced by
physicians who have medical education and pediatric care responsibilities, and if those problems are associated to
their workplace, medical specialty and area of clinical practice.
Methods: A self-applied semi-structured questionnaire was answered by 88 physicians with teaching and pediatric
care responsibilities. Content analysis was performed to analyze the qualitative data. Poisson regression was used
to explore the association of the categories of ethical problems reported with workplace and professional specialty
and activity.
Results: 210 ethical problems were reported, grouped into five areas: physician-patient relationship, end-of-life
care, health professional conducts, socioeconomic issues and health policies, and pediatric teaching. Doctors who
worked in hospitals as well as general and subspecialist pediatricians reported fewer ethical problems related to
socioeconomic issues and health policies than those who worked in Basic Health Units and who were family
doctors.
Conclusions: Some ethical problems are specific to certain settings: those related to end-of-life care are more
frequent in the hospital settings and those associated with socioeconomic issues and public health policies are
more frequent in Basic Health Units. Other problems are present in all the setting of pediatric care and learning
and include ethical problems related to physician-patient relationship, health professional conducts and the
pediatric education process. These findings should be taken into consideration when planning the teaching of
ethics in pediatrics.
Trial registration: This research article didn’t reports the results of a controlled health care intervention. The study
project was approved by the Institutional Ethical Review Committee (Report CEP-HIJG 032/2008).

Background The Brazilian Constitution [5] (Article 227) and the

Many facets of contemporary society are challenging the Child and Adolescent Statute [6] (Law 8069/90), which
health care arena and demand constant reflection about domestically put into force the International Convention
the best professional attitudes to be taken in a diversity on the Rights of the Child and the Universal Declaration
of circumstances. In this context, the current way of of the Rights of the Child, establish Brazil’s policy of full
teaching ethics in medicine has been changed and trans- protection for children as law. These legal instruments
cends the traditional model of deontological ethics. The conceive of children as citizens who have full rights and
moral education and the rescue and cultivation of quali- who are subject to protective priority because of their
ties and attitudes of a virtuous person required for good physical, psychological and moral vulnerability. How-
medical practice (virtue-based ethics) has been a press- ever, despite the legislative and social advances of recent
ing need [1-4]. decades, Brazil still has significant work to do to
advance the care and protection of children and adoles-
* Correspondence: juceliaguedert@[Link] cents, especially regarding access to quality education
† Contributed equally
Postgraduate Program in Medical Sciences, Federal University of Santa and the fight against malnutrition, child labor, abuse,
Catarina, Florianópolis, Brazil neglect and all forms of violence against children.
© 2012 Guedert and Grosseman; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Guedert and Grosseman BMC Medical Ethics 2012, 13:2 Page 2 of 9
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Pediatrics, an area with complex interpersonal interac- sample was selected by convenience. The estimated
tions and heavily influenced by emotions, has the poten- sample size of 72 participants was calculated using the
tial to give rise to situations involving ethical problems. Epi Info 2000 software and the following parameters: a
Entities engaged in medical education have developed total of 173 physicians, prevalence of 60% of ethical pro-
and released key documents on ethical and professional blems reports, relative risk of 3.0, test power of 80%
values and qualities desired for physicians [7-9]. Some (beta error type) and a 95% confidence interval (alpha
documents are directed to pediatricians [10-13] and dis- error type). Initially, 110 physicians were invited to par-
cuss the methods for teaching ethical and professional ticipate in the study; two declined, and 20 (16 from hos-
values to undergraduates and residents in pediatrics pitals and 4 from BHUs) accepted to participate but did
[10,13]. not complete the data collection instrument. Thus, the
However, there is still a gap between the ethical con- final convenience sample was composed of 88 physi-
tent taught in the universities and the ethical problems cians, 72 who worked in hospitals and 16 who worked
faced in clinical practice [14]. In addition to concerns in BHUs.
about the adequacy of the formal curriculum, the influ- After approval of the study project by the Research
ence of the hidden curriculum, that can lead students to Ethics Committee of the Joana de Gusmão Children’s
learn and repeat the behavior observed in the supervi- Hospital-Florianopolis, Brazil (Report 032/2008), data
sors and teachers, sometimes not adequate, has been were collected by a self-applied, semi-structured ques-
highlighted for a long time [10,13,15,16]. This demands tionnaire based on Taquette et al. [17], with three sec-
the identification of the ethical problems faced in all the tions with the following aspects: 1. Closed-ended
learning settings and the seek for primacy in ethical questions with socio-demographic and occupational
behaviors. variables: gender, marital status, religious belief, length
Given that it is very important that medical students of time working as a physician, medical specialty, pedia-
reflect about the best professional attitudes required to tric area of activity, ethics/bioethics training, workplace;
face the most common ethical problems that may arise 2. Open-ended questions requesting the report of up to
in the different contexts where they attend children and three situations experienced in the care of children and
adolescents, this study was developed to analyze the adolescents that represented an ethical dilemma, the
ethical problems experienced by physicians who have feelings aroused in those situations, who or what helped
medical education and children and pediatric care and could have helped, what aids were used to the pro-
responsibilities, and if those problems are associated to cess of decision making and what was done; 3. Open-
the workplace, their medical specialty and area of clini- ended question requesting suggestions for strategies to
cal practice. best approach these situations. A pilot study was per-
formed with 15 eligible participants.
Methods The term ethical dilemma was used in the question-
The study design had a mixed approach: cross-sectional, naire, because it is the most used term in the medical
observational, descriptive and inferential and qualitative field for the situations that the authors intended to
exploratory. The study population was composed of study. Conceptually, dilemma corresponds to a situation
physicians who had teaching activities with undergradu- in which only two choices are possible and only one of
ate medical students from the Universidade Federal de them can be correct [18]. As some situations reported
Santa Catarina (Federal University of Santa Catarina), by the participants did not involve dilemmas, to encom-
located in Florianópolis, capital city of Santa Catarina pass all the situations reported, we opted to use in this
State-Southern Brazil) and/or residents and who study the term ethical problem, a more comprehensive
attended children and adolescents in teaching hospitals concept, which involves situations for which we are not
or Basic Healthcare Units (BHUs). From the list pro- always able to identify solutions [18].
vided by the management sectors of these institutions Data analysis: A thematic content analysis of the qua-
and from the university, the universe of 173 physicians litative data was performed [19]. In the pre-analysis the
was identified: 136 worked in hospitals and 37 in BHUs. qualitative data were passed to an individual card with-
The inclusion criterion included: concurrent role as a out the sociodemographic data to ensure the anonymity
provider of children and adolescent health care and of and the analysis was performed separately by both
medical education (undergraduation and/or residents). researchers by grouping the data into units of meaning
The exclusion criteria were: being a resident, being and then categorizing them. In posterior meetings, the
retired or licensed, not having direct contact with trai- categories listed by each researcher were discussed and
nees in pediatrics and not working with child care. the definite categories were decided by consensus.
To ensure that all the pediatric subspecialists working Those categories were entered as categorical variables
in the settings surveyed would be represented, the into a Microsoft Office Excel © database (Microsoft
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Corporation, U.S.) along with the other variables in the - To deal with difficult relationship with the patients’
questionnaire. In addition to descriptive analysis, the asso- parents;
ciation between the frequency of each category of ethical - To cope with unexpected reactions from family
problems reported (outcome) and the participant sociode- members;
mographic and occupational characteristic (independent - To manage parents beliefs;
variable) was tested using chi2 or Fischer Exact Test when - Conflicts involving the autonomy of parents and
appropriated. For the outcome “ethical problem category” adolescents.
a Poisson regression was performed, to analyze the preva- b. End-of-life care [n = 55 (26.2%, CI: 20.3-32.1)],
lence ratios (PR) of the following exposure variables: medi- which involved challenges and conflicts in terminal
cal specialty [i.e., pediatrics or family medicine situations including issues such as:
(reference)], area of practice in pediatrics [i.e., pediatric - To take the decision to withdraw or whether to
subspecialty, general pediatrician or family physician withhold or not advanced life support, nutritional sup-
(reference)] and workplace [i.e., hospital or primary care port and resuscitation;
(reference)]. Because family physicians and other pediatri- - To accept the decision of colleagues of admitting the
cians who worked in BHUs did not report ethical pro- patient in the Intensive Care Unit;
blems related to end-of-life care, to estimate the PR of this - To accept the decision of colleagues of prescribing
outcome, only the variables general pediatrician versus futile therapies;
subspecialist pediatrician were used. This analysis was - To deal emotionally with the situation of patients
adjusted for the following confounding variables: gender, without therapeutic perspectives;
age, marital status, religious belief, training in ethics and - To diagnose brain death.
bioethics, and length of time working as a physician. c. Health professionals conducts [n = 50 (23.8%, CI:
To ensure proportionality, the sample was weighed in 18.0-29.6)], which comprised disagreement with physi-
relation to the frequency of general pediatricians, sub- cians or other health professionals conducts such as:
specialist pediatricians and family physicians in the uni- - To disagree with colleagues in the indication of
verse of physicians with teaching activities with students procedures;
from the Universidade Federal de Santa Catarina and - To witness workplace inappropriate attitudes of col-
children care practice in the 2 teaching hospitals and in leagues in their relationship with patients and other
the Basic Healthcare Units. For the statistical analysis, colleagues;
Stata 11.0 (StatCorp, College Station, TX, US) was used. - To disagree with inappropriate personal attitudes of
A significance level of p < 0.05 was adopted. physicians from other workplaces;
- To disagree with inappropriate patient relationship
Results of physicians from other workplaces;
The average age of the 88 participants was 44.1 years - To disagree with the breach of confidentiality, inap-
(CI: 42.2-46.1), the average length of time working as a propriate use of medicines or inappropriate personal
physician was 19.6 years (CI: 17.6-21.5), the average attitudes of other health professionals.
time spent in daily care of patients was 6.8 hours (CI: d. Socioeconomic issues and public health policy [n
6.3-7.4) and that spent on medical students and resi- = 31 (14.8%, CI: 10.0-19.6)], which involved challenges
dents education was 2.3 (CI: 1.8-2.7). concerning socioeconomic conditions and the public
Among the 210 reports, five broad categories of ethi- health care system that influence patient treatment,
cal problems were identified. These ethical problems management and protection such as:
[with their frequencies, including absolute number (n), - To have to take decisions when the absence of inpa-
percentage (%) and 95% Confidence Interval (CI)] were tient beds threatens the lives of patients and surgeries
related to: are postponed;
a. Physician-patient relationships [n = 61 (29.0%, CI: - To cope with the social reality of patients, which
2.9-35.1)], which comprised difficult interactions with the imposes limits to the adequate management of care,
patients and/or their families including issues such as: resulting in lack of therapeutic success;
- To ensure confidentiality, especially in adolescent - To cope with the difficulty in referring patients to
care; specialists;
- To cope with difficult revelations (communication of - To cope with violence against children, including
bad news, disclosure of diagnosis, disagreement with neglect;
diagnosis given by other physician); - To experience problems in the workplace, among
- To cope with parents non-adherence to patients’ them, the lack of specialists, of equipments and of
treatment; material;
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- To cope with problems in the health care system exposure of patients and discussion of cases in
that result in difficulties for patients to have access to corridors;
more sophisticated diagnostic exams and to surgeries. - To experience problems in the relationship between
e. Pediatric Education Process [n = 13 (6.2%, CI: 2.9- teachers/physician supervisors, such as public criticism
9.5)], which comprised inadequate personal attitudes and disrespect authorship in scientific publication;
and interpersonal interactions in the academic environ- - To witness problems in the personal attitudes of
ment including relationship between: student-teacher/ undergraduates and residents.
supervisor, teacher-supervisor, teacher/supervisor- The distribution of the ethical problems reported
patient, student-patient, teachers-physicians of Basic according to the sociodemographic and occupational
Health Units such as: characteristics of the participants is presented in Table 1.
- To witness an ethically reprehensible attitudes of the In Poisson regression, it was found that fewer ethical
teachers; problems related to the SEPHP were reported among
- To witness medical undergraduate students disre- the participants who worked in hospitals when com-
spect for the university hierarchy; pared to those who worked in the Basic Health Units
- To experience problems such as the allowance by [PR = 0,3 (CI 95% 0,12-0,72)] (Figure 1), as well as
teacher/physician supervisor to residents to act when among those whose clinical practice is as pediatrician
there is risk to the patient; (general and subspecialties in pediatrics) [PR = 0,34 (CI
- To experience problems in the relationship profes- 95% 0,14-0,81)] when compared to clinical practice as
sor/physician supervisor-patient, such as inadvertent family physicians (Figure 2). This association was

Table 1 Distribution of the ethical problems according sociodemographic and occupational characteristics of the
participants.
Ethical Problems related to*
Participants characteristics n (%) PPR ELC HPC SEPHP PEP
(row%) (row%) (row%) (row%) (row%)
Gender
Male 38 (43.2) 50.0 36.8 39.5 26.3 5.3
Female 50 (56.8) 42.0 42.0 40.0 28.0 12.0
Marital Status
Single 18 (20.4) 44.4 44.4 33.3 33.3 16.7
Married 60 (68.2) 50.0 38.3 43.3 23.3 6.7
Divorced 08 (9.1) 25.0 37.5 37.5 37.5 12.5
Living with partner 02 (2.3) - 50.0 - 50.0 -
Religious belief
Yes 72 (81.8) 43.1 41.7 40.3 26.4 8.3
No 16 (18.2) 56.3 31.3 37.5 31.3 12.5
Specialty Area
General pediatrics 16 (18.2) 31.3 31.3‡ 62.5 18.8 6.3
Pediatric subspecialty 58 (65.9) 46.6 51.7‡ 36.2 24.1 10.3
Family Medicine 14 (15.9) 57.1 0.0‡ 28.6 50.0† 7.1
Bioethics/bioethics training
Yes 37 (42.0) 54.1 37.8 37.8 27.0 13.5
No 49 (55.7) 38.8 40.8 40.8 26.5 6.1
Non respondents 2 (2.3) - - - - -
Workplace
Teaching Hospital 72 (81.8) 41.7 48.6# 41.7 22.2† 9.7
Basic Health Unit 16 (18.2) 62.5 0.0# 31.3 50.0† 6.3
(Florianópolis-Brazil, 2010)
Notes: PPR Physician-Patient Relationship; ELC End of life Care; HPC Health Professional Conducts; SEPHP Socioeconomic issues and Public Health Policies; PEP
Pediatric Education Process
*Values exceed 100% for the possibility of up to 3 reports by participant; the association between the category of ethical problem and participant characteristics
was tested by Chi2 or Fisher exact when appropriated; † p < 0,05; ‡ p < 0,01; # p < 0,001.
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Figure 1 Prevalence Ratio: work in hospitals compared to work in the Basic Health Units (exposure) and presence of at least one
report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life Care (not reported by family
physicians) and Pediatric Education Process (CI very broad).

Figure 2 Prevalence Ratio: clinical practice is as pediatrician compared to clinical practice as family doctor (exposure) of at least one
report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life Care (not reported by family
physicians) and Pediatric Education Process (CI very broad).
Guedert and Grosseman BMC Medical Ethics 2012, 13:2 Page 6 of 9
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maintained when medical specialties were compared: of a meeting of experts in pediatric education [10]
family physicians to subspecialists pediatricians and gen- which was conducted in 2007. They concluded that the
eral pediatricians [PR = 0,3 (CI 95% 0,09-0,98) and PR = activities of pediatricians in their various work environ-
0,35 (CI 95% 0,14-0,85)] (Figure 3). There was no statis- ments and subspecialties are sufficiently different to jus-
tical significance in the prevalence ratio of ethical pro- tify different training depending on the environment in
blems related to PPR, HPC and PEP, when comparing which the professional is located. However, a high fre-
workplaces, medical specialties and areas of clinical quency of reports concerning interpersonal relationships
practice, which shows that the frequency of reports of was noted and was experienced equally in the health
these categories of ethical problems was similar among care and education settings. These relationships involve
the participants. The category of ethical problems physicians, patients and families, the various profes-
related to end of life was only reported by the partici- sionals working in pediatric care, students, residents,
pants who worked in Hospitals and no statistical signifi- teachers and supervisors.
cance was found in the prevalence ratio of this category The fact that many reports involved the physician-
when comparing general pediatricians to subspecialty patient relationship reflects the importance that should
pediatricians. be given to this subject in medical education. It is well
established that this relationships should be of caring,
Discussion built in the light of ethics and that it is strongly influ-
This study showed that the ethical problems experi- enced by the moral values of those involved in this pro-
enced in the daily care of children and adolescents go cess, by the culture, the society and by the manner
beyond those usually described in the literature [20-22] which the health care system is structured. To achieve
and cover areas that should be planned for and the ideal standard of this interaction, the American
addressed in the curricula for students of pediatrics. Academy of Pediatrics (AAP) has established eight com-
Some problems were more specific to certain work- ponents of professionalism to teaching and assessment
places, such as those related to end-of-life care situa- in pediatrics. Of these, six are directly related to the atti-
tions occurring in hospitals and those related to tudes and values expected from the physician in relation
socioeconomic issues and health policies occurring in to the patient (honesty and integrity, reliability and
primary care. This observation reinforces the conclusion responsibility, respect for others, compassion and

Figure 3 Prevalence Ratio: medical specialty-general pediatrician or subspecialist pediatrician compared to family doctor (exposure)
and presence of at least one report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life Care
(not reported by family physicians) and Pediatric Education Process (CI very broad).
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empathy, communication and collaboration, and altru- hospitals, especially those in pediatric subspecialties who
ism and defense) and the other two (self-improvement are entrusted with the care of critically ill children and
and self-awareness and knowledge of limits) relate to adolescents [26-33]. They reinforce the need for physi-
physician singular skills. These components must be cians to have skills to cope with these situations so that
worked on throughout medical education and on an their decision-making can achieve the patient’s best
ongoing process of continuing education after gradua- interests.
tion [12]. The socioeconomic context and public health policies
Ethical problems involving conduct of health profes- are complex and are an inseparable part of medical
sionals also occurred in all surveyed environments. The activity, as they are directly related to the medical work,
situations included in this category, such as divergences particularly of those who attend pediatric patients, due
in personal and professional conduct and difficulties in to the the eco-dependency of the child. Problems of this
maintaining privacy, demonstrate the importance of scope are related to Social and Community pediatrics,
developing negotiating skills and improving interactions which for almost a decade was considered by DeWitt
with all participants in the health care network. Delany [34] as the greatest challenge for the planning of educa-
et al. [15] name as “allied health” in Pediatrics the pro- tional activities, as it requires the inclusion of issues
fessionals from many specialized health professions who related to equity in child health and social justice. It is
work in the pediatric area in the health care team, in the community context that the student has the
attending children and adolescents with acute and opportunity to interact with the social determinants of
chronic diseases or with disabilities. The relationship health, to promote preventive action at different levels
between physicians and these professionals may lead to and to develop an interest in protecting children’s rights
ethical problems due to their differing perspectives of [34,35]. In recent years, the relevance of teaching pedia-
what constitutes the best interests of the child, which trics in the community [34,36] has been recognized, and
depend on what the authors call “disciplinary paradigms efforts have been made to change the predominantly
of care or operational philosophy.” For these authors, it hospital teaching model and insert the students in all
is necessary that the professional who attends the pedia- levels of care. Decision-making in this context involves
tric age group be aware of his role as moral agent, of interdisciplinary team work, depends on political deci-
his professional responsibility and of the impact of his sions and is often hampered by the need for changes in
decisions in the children and their families lives when the political and social structure in which the child is
he refers the patient to allied professionals [15]. placed. Pediatrics education must address issues of this
Although the PEP ethical problems were reported by nature and there is a need for faculty development to
teachers and supervisors, the findings coincide with the ensure adequate orientation of students at this level
finding of studies with students reports [21-25] which [37]. Also, pediatricians and family physicians can con-
involved mainly disrespect when relating with patients, tribute positively to the encouragement, support and the
colleagues and students. The study reveal that in the establishment of effective partnerships with families
education process it is essential an adequate communi- [38], having active participation in health care teams.
cation between the parties and that it is expected that The AAP suggests that philosophies, principles and
the teacher/supervisor be a role model and also that the practices should be focused and targeted at health care
student have appropriate ethical attitudes, especially a in the family (family-oriented care), i.e., the family
respectful way in the interaction with patients and tea- should be considered the unit of care and intervention.
chers, and, for achieving this, educational actions are This approach make easier the understanding of the
also needed. physician responsibilities, since the assessment of the
The ethical problems related to end of life care were emotional and social problems that affect the welfare of
those more closely related to the impact of technological the child must always be included [38].
development in health, which require constant reflection The generalizability of the findings of our study is lim-
of the ethical aspects. For this area, some of the impor- ited, as the topic of ethics is influenced by socio-cultural
tant subjects in the teaching of Ethics in pediatrics characteristics and because there are regional differences
should be emphasized such as the limits of prematurity, in the characteristics of pediatric care and medical teach-
advanced life support in children with very limiting dis- ing. Other limitations may be related to the fact that the
abilities and severe malformations, do-not-resuscitate sample may be representative only of the environment
orders, therapeutic futility and palliative care, technol- where the research was conducted (Southern Brazil).
ogy-dependent children and the use of off-label medica- Despite this fact, we expect that this study contributes as
tions. Previous studies addressing these issues, which a basis for comparison with other cultures and regions
were developed in different settings, highlight the diffi- and to the formulation of educational initiatives leading
culties encountered by professionals working in to the teaching of ethics and professionalism geared
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towards the practice of health care among children and Authors’ contributions
JMG conceived of the study, participated in its design, data collection and
adolescents. In this context, the ethical problems, experi-
analysis and drafted the manuscript. SG conceived of the study, participated
enced in different settings, reported in our study by in its design, data analysis, as well as in the critical review of the manuscript.
pediatricians and family physicians who participate in the All authors read and approved the final manuscript.
medical education process and attend children and ado-
Competing interests
lescent could be used in the medical undergraduation, The authors declare that they have no competing interests.
graduation and postgraduation curriculum and in faculty
Received: 2 November 2011 Accepted: 16 March 2012
development programs as a means to raise critical reflec-
Published: 16 March 2012
tion for and on action and promote ethical attitudes and
professionalism. References
1. Buyx AM, Maxwell B, Schone-Seifert B: Challenges of educating for
medical professionalism: who should step up to the line? Med Educ 2008,
Conclusions 42(8):758-764.
Some ethical problems that are experienced by physi- 2. Dingle AD, Stuber ML: Ethics education. Child Adolesc Psychiatr Clin N Am
cians who treat children and adolescents are more speci- 2008, 17(1):187-207.
3. Roberts LW, Warner TD, Hammond KA, Geppert CM, Heinrich T: Becoming
fic to the workplace. Problems related to end-of-life
a good doctor: perceived need for ethics training focused on practical
care, such as those related to the decision to withdraw and professional development topics. Acad Psychiatry 2005, 29(3):301-309.
or withhold advanced life support, nutritional support 4. Singer PA, Pellegrino ED, Siegler M: Clinical ethics revisited. BMC Med
Ethics 2001, 2:E1.
and resuscitation, are more frequent in the hospital set-
5. Brazil: [Constitution of the Federative Republic of Brazil]. [[Link]
ting. Ethical problems associated with socioeconomic [Link]/IMG/pdf/[Link]].
issues and public health policies that influence patient 6. Brazil: [Child and Adolescent Statute. Law 8069/90]. [[Link]
[Link]/ccivil_03/leis/[Link]].
treatment, care and child protection are more frequent
7. ACGME Outcome Project. [[Link]
in Basic Health Units. Therefore, educational strategies 8. Inui TS: A flag in the wind: education for professionalism in Medicine
to aid in the decision-making process and the ethical Washington: Association of American Medical Colleges; 2003.
9. Members of the Medical Professionalism Project (ABIM Foundation A-AF
reflection on end-of-life care situations in pediatrics
European Federation of Internal Medicine): Medical professionalism in the
should be addressed among medical students and pro- new millennium: a physician charter. Ann Intern Med 2002, 136(3):243-246.
fessionals to prepare them for pediatric practice in hos- 10. Abbott MB, First LR: Report of colloquium III: challenges for pediatric
graduate medical education and how to meet them–a quality
pitals. The ethical problems related to socio-economic
improvement approach to innovation in pediatric graduate medical
issues and public health policies need to be approached education. Pediatrics 2009, 123(Suppl 1):S22-S25, 2009/01/06.
in pediatrics and adequately discussed, specially linked 11. Fallat ME, Glover J: Professionalism in pediatrics: statement of principles.
Pediatrics 2007, 120(4):895-897.
to the teaching of pediatric primary health care and to
12. Fallat ME, Glover J: Professionalism in pediatrics. Pediatrics 2007, 120(4):
the community practice. e1123-e1133.
Others problems, however, are present in all the set- 13. Lang CW, Smith PJ, Ross LF: Ethics and professionalism in the pediatric
curriculum: a survey of pediatric program directors. Pediatrics 2009,
tings of pediatric care and learning and include ethical
124:1143-1151.
problems related to physician-patient relationships, 14. Carrese JA, Sugarman J: The inescapable relevance of bioethics for the
health professional conducts and the pediatrics educa- practicing clinician. Chest 2006, 130(6):1864-1872.
15. Delany C, Spriggs M, Fry CL, Gillam L: The unique nature of clinical ethics
tion process. So, the teaching of communication skills
in allied health pediatrics: implications for ethics education. Camb Q
for effective physician-patient relationship and interdis- Healthc Ethics 2010, 19(4):471-480.
ciplinary team work, anchored in professionalism in 16. Goldie J: Review of ethics curricula in undergraduate medical education.
Med Educ 2000, 34(2):108-119.
pediatrics, rooted on ethical attitudes, should be planned
17. Taquette SR, Rego S, Schramm FR, Soares LL, Carvalho SV: Ethically
and provided along all the years of medical course, in conflicting situations experienced by medical students. Rev Assoc Med
academic activities at all the levels of health and should Bras 2005, 51(1):23-28.
18. Gracia D: Moral deliberation: the role of methodologies in clinical ethics.
be present in all the learning environments.
Med Health Care Philos 2001, 4(2):223-232.
Given the importance and frequency of the ethical 19. Bardin L: [Content analysis]. 4a edition. Lisboa: Edições 70; 2010.
problems reported by the physician in different settings 20. Forman EN, Ladd RE: Ethical dilemmas in pediatrics: a case study approach
Lanham: University Press of America; 1995.
of pediatric clinical practice, they could be used in the
21. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI: Understanding
training of students, physicians and faculty as a means the clinical dilemmas that shape medical students’ ethical development:
to raise critical reflection for and on action and promote questionnaire survey and focus group study. BMJ 2001,
322(7288):709-710.
ethical attitudes and professionalism.
22. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS: Medical students’
professionalism narratives: a window on the informal and hidden
curriculum. Acad Med 2010, 85(1):124-133.
Acknowledgements 23. Caldicott CV, Faber-Langendoen K: Deception, discrimination, and fear of
We thank Fernando Wehrmeister for his contribution to the statistical reprisal: lessons in ethics from third-year medical students. Acad Med
analysis and Isabela Giuliano for the critical review of manuscript. 2005, 80(9):866-873.
Guedert and Grosseman BMC Medical Ethics 2012, 13:2 Page 9 of 9
[Link]

24. Kelly E, Nisker J: Increasing bioethics education in preclinical medical

curricula: what ethical dilemmas do clinical clerks experience? Acad Med
2009, 84(4):498-504.
25. Reddy ST, Farnan JM, Yoon JD, Leo T, Upadhyay GA, Humphrey HJ,
Arora VM: Third-year medical students’ participation in and perceptions
of unprofessional behaviors. Acad Med 2007, 82(10 Suppl):S35-S39.
26. Floriani CA: Home-based palliative care: challenges in the care of
technology-dependent children. J Pediatr (Rio J) 2010, 86(1):15-20.
27. Friedman SL, Helm DT, Marrone J: Caring, control, and clinicians’
influence: ethical dilemmas in developmental disabilities. Ethics Behav
1999, 9(4):349-364.
28. Peerzada JM, Richardson DK, Burns JP: Delivery room decision-making at
the threshold of viability. J Pediatr 2004, 145(4):492-498.
29. Pinter AB: End-of-life decision before and after birth: changing ethical
considerations. J Pediatr Surg 2008, 43(3):430-436.
30. Shah SS, Hall M, Goodman DM, Feuer P, Sharma V, Fargason C Jr, Hyman D,
Jenkins K, White ML, Levy FH, et al: Off-label drug use in hospitalized
children. Arch Pediatr Adolesc Med 2007, 161(3):282-290.
31. Soares M, Terzi RG, Piva JP: End-of-life care in Brazil. Intensive Care Med
2007, 33(6):1014-1017.
32. van Zuuren FJ, van Manen E: Moral dilemmas in neonatology as
experienced by health care practitioners: a qualitative approach. Med
Health Care Philos 2006, 9(3):339-347.
33. Wright B, Aldridge J, Wurr K, Sloper T, Tomlinson H, Miller M: Clinical
dilemmas in children with life-limiting illnesses: decision making and
the law. Palliat Med 2009, 23(3):238-247.
34. DeWitt TG: The application of social and adult learning theory to training
in community pediatrics, social justice, and child advocacy. Pediatrics
2003, 112(3 Part 2):755-757.
35. American Academy of Pediatrics: Policy statement-The future of
pediatrics: mental health competencies for pediatric primary care.
Pediatrics 2009, 124(1):410-421.
36. Puga TF, Benguigui Y: Pediatric training in medical schools of Latin America
Washington: PAHO; 2006.
37. Roberts KB, DeWitt TG: Faculty development of pediatric practitioners:
complexities in teaching clinical precepting. Pediatrics 1996, 97(3):389-393.
38. Schor EL: Family pediatrics: report of the task force on the family.
Pediatrics 2003, 111(6 Pt 2):1541-1571.

Pre-publication history
The pre-publication history for this paper can be accessed here:
[Link]

doi:10.1186/1472-6939-13-2
Cite this article as: Guedert and Grosseman: Ethical problems in
pediatrics: what does the setting of care and education show us? BMC
Medical Ethics 2012 13:2.

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