Child health care in primary health care: conflicts (bio)ethics

Brito, Mirna Peçanha; Silva, Eugênio; Siqueira-Batista, Rodrigo

doi:10.1590/1983-80422021293487

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Research • Rev. Bioét. 29 (3) • Jul-Sep 2021 • https://doi.org/10.1590/1983-80422021293487 copy

Child health care in primary health care: conflicts (bio)ethics

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Abstract

Although quite complex, bioethical conflicts in the daily routine of child and adolescent health care in primary health care have been little addressed, unlike what occurs at the tertiary care level. Providing support to this especially vulnerable population involves conflicts that require from the health professional, in addition to technical competence, a series of essential legal knowledge and ethical attributes. Therefore, it is important to recognize and analyze the pertinent (bio)ethical issues in order to enable decision-making that is in the best interests of the child. From a literature review, this article aims to delimit the main ethical conflicts related to child health care in primary health care.

Child; Pediatrics; Bioethics; Ethics; Primary health care; Family health

Author, year, title	Journal	Type of study and bioethical approach	Conflict in everyday outpatient clinical practice
Constantino; 2010¹⁵, “Contracepção de emergência e adolescência: responsabilidade e ética”.	Revista Bioética	Descriptive, principlist approach.	Emergency contraception to prevent teenage pregnancy; secrecy; confidentiality.
García Mendiola and collaborators; 2010¹⁶, “Dilemas éticos y bioéticos de la práctica pediátrica en la atención primaria de salud”.	Medisur	Descriptive, principlist approach.	Prenatal diagnosis (principle of respect for autonomy, as in the decision on birthing a child, even with diseases incompatible with life); immunization programs; care for children with disabilities (especially encephalopathy and congenital heart disease); children victims of abuse; care for children from religious families; drug indication, mainly for respiratory diseases.
Sarmiento; 2010¹⁷, “Bioética e infancia: compromiso ético con el futuro”.	Persona y Bioética	Descriptive, principlist approach.	Protection of children in situations of social risk, such as poverty, maltreatment, labor exploitation and involvement in armed conflicts. Protection must be considered not only an ethical duty, but also a promoter of the child’s development into an adult capable of responsibly exercising autonomy.
Taquette; 2010¹⁸, “Conduta ética no atendimento à saúde de adolescentes”.	Adolescência & Saúde	Literature review, principlist approach.	Ethical conflicts in disagreement with legislation, poverty, violence, sexual activity before 15 years of age, scientific research, relationship between physician and adolescent patient, autonomy, privacy, confidentiality and sexuality. Study sought to help health professionals make ethical decisions for the benefit of adolescents based on knowledge of the legislation.
Martínez Delgado, Rodríguez Prieto, Cuan Colina; 2011¹¹, “Aspectos éticos en pediatría”.	Revista Cubana de Pediatría	Bibliographic review, principlist approach.	Relationship between health professional, patient and family; informed consent; consent to the therapeutic act; communication and information.
Nulty; 2011¹⁹, “Is it ethical for a medical practice to dismiss a family based on their decision not to have their child immunized?”	JONA’S Healthcare Law, Ethics, and Regulation	Case report, principlist approach.	A health care professional’s refusal to care for children whose family denies the necessary immunizations is contrary to the bioethical principles of respect for autonomy, beneficence, and justice. a family that refuses to have their child vaccinated should be given the same respect, support, and compassion as other patients.
Guedert, Grosseman; 2011¹⁴, “Abordagem dos problemas éticos em pediatria: sugestões advindas da prática”.	Revista Brasileira de Educação Médica	Cross-sectional, descriptive, exploratory, qualitative, and quantitative study; principlist approach.	Physician-patient relationship (confidentiality, difficult personal relationships, and diagnostic disclosures); conduct of health professionals and related areas in the face of disagreement regarding therapeutic indications; and public health policies (especially those related to unfavorable socioeconomic conditions, inadequate health care network and work environment, and violence against children).
Madeira; 2011²⁰, “A bioética pediátrica e a autonomia da criança”.	Residência Pediátrica	Literature review, principlist approach.	Decision making must respect the patient’s family values and the principles of bioethics, but we must understand that the child is a moral being in development, and in this case the principle of respect for autonomy is relative, sine one has to consider the different stages of the infant’s cognitive and psychosocial development.
Guedert, Grosseman; 2012²¹, “Ethical problems in pediatrics: what does the setting of care and education show us?”	BMC Medical Ethics	Study design of mixed approach: cross-sectional, observational, descriptive and inferential, qualitative and exploratory.	Physician-patient relationships; terminal patients; health professional conduct; weakness of the teaching-learning process; precariousness of the health care network.
Santos, Santos, Santos; 2012²², “A confidencialidade médica na relação com o paciente adolescente: uma visão teórica”.	Revista Bioética	Nonsystematic literature review, principlist approach.	Emphasis on confidentiality in the relationship between physician and adolescent patient, having in mind that confidentiality is not an exclusive right of adults. It is a value also provided by law for the pediatric age group. Professionals must assess the adolescent’s development to progressively let them exercise their autonomy.
Barbosa, Guedert, Grosseman; 2013²³, “Problemas éticos relatados por internos com ênfase na saúde da criança”.	Revista Brasileira de Educação Médica	Study with a mixed approach: quantitative, cross-sectional and descriptive; qualitative-exploratory. Principlist approach.	Inappropriate professional attitudes; respect for autonomy, secrecy, and confidentiality; life-limiting situations; breaking bad news; physical or psychological violence; precariousness of the teaching-learning process; fragility of the health care network.
Moreira and collaborators; 2013²⁴, “Adolescência e sexualidade: uma reflexão com enfoque bioético”.	Adolescência & Saúde	Descriptive, qualitative research, principlist approach.	In adolescent care, attention to ethical, bioethical, legal and psychological aspects, as well as sexual counseling, aims to provide comprehensive care to developing individuals. Privacy and confidentiality are important factors for a preventive approach to maltreatment, sexual abuse, neglect, and violence.
Opel and collaborators; 2014²⁵, “A 6-month-old with vaccine-hesitant parents”.	Pediatrics	Case report, principlist approach.	Many primary care professionals consider the refusal of vaccination by parents one of the most contentious situations they face, given the effectiveness of immunization in reducing child mortality. Many pediatricians are legally liable for not attending children whose parents refuse vaccination. Some professionals even consider that the parents’ refusal justifies referral to child protection services. This situation illustrates the ethical conflict in public health: how to weigh values of an individual choice and the common good?
Almeida, Lins, Rocha; 2015²⁶, “Dilemas éticos e bioéticos na atenção à saúde do adolescente”.	Revista Bioética	Systematic literature review, principlist approach.	Secrecy and confidentiality in consultation; maltreatment; practice of illegal activities, such as abortion and drug use; sexual activity before the age of 14; health professionals who disclose information recorded in medical records; exploitation of the adolescent labor; and lack of government resources to purchase medication needed for health care. The authors reinforce the need for ethical, bioethical, and legal knowledge involved in child and adolescent health care.
Casado Blanco, Hurtado Sendin, Castellano Arroyo; 2015²⁷, “Dilemas legales y éticos en torno a la asistencia médica a los menores”.	Pediatría Atención Primaria	Descriptive, deontological approach.	Ethical conflicts are most evident in pediatric care, where the patient is a minor and, therefore, has an impeded or limited exercise of rights. The authors address the issue of minors emancipated for marriage. The article aims to advise pediatricians and general practitioners on legal, ethical, and deontological norms for decision-making in medical care.
Bow; 2015²⁸, “Singling out the double effect: sexual health advice and contraception are ethically distinct”.	London Journal of Primary Care	Descriptive, principlist approach.	In the UK, sexual intercourse with anyone under 16 is considered a crime. In light of St. Thomas Aquina’s “double effect,” which is based on the distinction between the intended and the foreseeable, the article discusses ethical and legal issues related to the work of professionals who provide contraceptives and sexual counseling to adolescents under 16 years of age. In conclusion, provision of contraceptives is not justified by the doctrine of double effect, and is therefore an illegal act.
Lantos; 2015²⁹, “The patient-parent- pediatrician relationship: everyday ethics in the office”.	Pediatrics in Review	Descriptive, principlist approach.	Home births; parents’ refusal to perform routine procedures or immunize healthy newborns; prescription of contraceptives for adolescents; maltreatment; secrecy and confidentiality about adopted children; and testing for drug use without the adolescent’s consent.
Block; 2015³⁰, “The pediatrician’s dilemma: refusing the refusers of infant vaccines”.	Journal of Law, Medicine & Ethics	Editorial note.	The article discusses ethical and legal issues related to attending parents who refuse to vaccinate their children. It concludes that the patient’s well-being should be the main motivating factor for care.
Moreno Villares; 2017³¹, “Dilemas éticos en la práctica de la medicina infantil”.	Cuadernos de Bioética	Literature review of the last 20 years: 80 articles read thoroughly. Principlist approach.	Conflicts were divided into 13 orders of problems: disability; parental stress due to children’s treatment; health professionals’ lack of training in child psychology and communication; dilemmas related to child palliative care; impasses related to informed consent; indecisions regarding patient data; dilemmas related to prevention; hesitations related to surgery; doubts regarding organ donation; issues related to pediatric endocrinology, such as in cases of obesity; ethical dilemmas regarding divorced parents; child maltreatment; requesting unnecessary tests and treatments.
Lozano Vicente; 2017³², “Bioética infantil: principios, cuestiones y problemas”.	Acta Bioethica	Descriptive, materialistic bioethics.	Bioethical reflection and practice must be adjusted to the developing individual. There must be synergy between bioethics, human rights, and socioenvironmental policies. Issues addressed were didactically divided into bioethics (autonomy, informed consent, secrecy, confidentiality), biomorals (child and adolescent sexuality, religious conflicts), and biopolitics (compulsory vaccination and education, legal issues related to child maltreatment).
Santos and collaborators; 2017³³, “Problemas éticos en la atención primaria: el contexto de la salud del niño”.	Bioética Complutense	Literature review.	Vaccination; child maltreatment; professional’s relationship with the patient’s family; socioeconomic issues in public health; and disorganization of care services.
Souza and collaborators; 2018³⁴, “Dilemas bioéticos na assistência médica às gestantes adolescentes”.	Revista Bioética	Integrative review, principlist approach.	Psychological conflicts due to induced abortion, usually clandestine and done dangerously; frictions related to privacy, confidentiality and autonomy; abortion in adolescence as an ethical problem in terms of public health.
Lozano Vicente; 2019³⁵, “Panorama da bioética infantil na América Latina”.	Revista Bioética	Review of the most relevant general indicators on health and social issues for children and public policies for protecting children, presenting a proposal to classify the main bioethical conflicts in Latin America.	The author discusses the main conflicts in children’s bioethics according to the standards involved, whether bioethical, biomoral, or biopolitical. According to Lozano Vicente, all bioethical issues concerning childhood are of great complexity, thus requiring interdisciplinary work that reconciles scientific, health, cultural, social, and ethical experiences.

Ethical conflicts	Types
1. Related to patient versus patient’s parents/caregivers versus healthcare professionals	Inappropriate professional attitudes
	Communication to clarify treatments, procedures and examinations
2. Linked to the child’s limited exercise of their fundamental rights	Autonomy
	Privacy and confidentiality
	Use of contraceptives in adolescence
	Teenage sex education
	Teenage pregnancy
3. Related to situations of vulnerability	Child maltreatment
3. Related to situations of vulnerability	Children with special needs
4. Associated with socioeconomic factors and public health policies	Parental refusal to vaccinate their children
	Poverty
	Child labor

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[1] Correspondence: Mirna Peçanha Brito – Universidade Federal de Viçosa. Av. Peter Henry Rolfs, s/n, Campus Universitário CEP 36570-900. Viçosa/MG, Brasil.