Moral Choice and Ethical Dilemas

Read the followin" rel="nofollow">ing attached PDF titled: • Moral choices in" rel="nofollow">in end of life care for children by Susan Strin" rel="nofollow">inger. Dated September 2013 | Volume 12 | Number 7 Writer, after you read the PDF File that I have attached by Susan Strin" rel="nofollow">inger please answer the followin" rel="nofollow">ing four (4) questions: 1. Describe the ways the subjects were vulnerable. 2. Is there any conflict of in" rel="nofollow">interest? 3. Which protections should be put in" rel="nofollow">in place to protect these subjects from harm? 4. What are the in" rel="nofollow">incidence and prevalence of moral distress in" rel="nofollow">in nursin" rel="nofollow">ing today? Reference Strin" rel="nofollow">inger, S. (2013). Moral choices in" rel="nofollow">in end of life care for children. Cancer Nursin" rel="nofollow">ing Practice, 12(7), 27-32 6p CANCER NURSING PRACTICE September 2013 | Volume 12 | Number 7 27 Art & science | ethics Moral choices in" rel="nofollow">in end of life care for children Susan Strin" rel="nofollow">inger outlin" rel="nofollow">ines different ethical stances and how they relate to the decision whether to discuss treatment with an 11-year-old patient End of life care is fraught with difficulties and ethical dilemmas, which are even more problematic in" rel="nofollow">in the case of children (Royal College of Paediatrics and Child Health 2004). Although many of the issues encountered are often unavoidable, they can be emotive (Garrard 2009). Common issues in" rel="nofollow">include the management of pain" rel="nofollow">in and other distressin" rel="nofollow">ing symptoms, uncertain" rel="nofollow">inties about the future, psychosocial, emotional and spiritual concerns, and providin" rel="nofollow">ing compassionate support for children and their families. Parents may face heart-breakin" rel="nofollow">ing dilemmas, such as whether to contin" rel="nofollow">inue aggressive life-sustain" rel="nofollow">inin" rel="nofollow">ing treatments, which may result in" rel="nofollow">in unbearable sufferin" rel="nofollow">ing; or allow their child to die. This article explores a case study of an 11-year-old boy with lymphoma to illustrate the ethical considerations of the decision-makin" rel="nofollow">ing process in" rel="nofollow">involved in" rel="nofollow">in his care. Three ethical issues – beneficence, autonomy and veracity – that are pertin" rel="nofollow">inent to the case study and that might need to be considered when providin" rel="nofollow">ing end of life care to children are discussed. The main" rel="nofollow">in elements of each of these ethical issues are examin" rel="nofollow">ined and their implications for clin" rel="nofollow">inical practice are appraised. Healthcare workers should not only acknowledge the importance of good end of life care, but should also recognise the different types of ethical issues that may arise. To put these ethical debates in" rel="nofollow">into context, it is necessary to establish defin" rel="nofollow">initions of palliative care and ethics, and consider their fundamental philosophies and perceptions. Palliative care In 1986, the World Health organization (WHo) defin" rel="nofollow">ined palliative care as: ‘The active total care of patients whose disease is not responsive to curative treatment.’ WHo stressed the importance of controllin" rel="nofollow">ing pain" rel="nofollow">in and other symptoms, and psychological, social and spiritual problems, to achieve optimum quality of life for patients and their families. Ahmedzai et al (2004) expressed concern that this defin" rel="nofollow">inition of palliative care could be construed as ‘relegatin" rel="nofollow">ing palliative care to the last stages of care’. The provision of palliative care is not restricted to those with in" rel="nofollow">incurable disease; consequently the origin" rel="nofollow">inal WHo defin" rel="nofollow">inition has been revised (WHo 2002) to in" rel="nofollow">include problems associated with ‘life-threatenin" rel="nofollow">ing illness’, emphasisin" rel="nofollow">ing the need to in" rel="nofollow">introduce palliative care earlier on in" rel="nofollow">in the disease process. other tenets of palliative care specified by WHo (1986) in" rel="nofollow">include the in" rel="nofollow">intention to ‘neither hasten nor postpone death’, so that dyin" rel="nofollow">ing is seen as a normal process. A further document was produced to take in" rel="nofollow">into account the comprehensive needs of children (WHo 1998). The aim of palliative care is to reduce physical, psychological and spiritual sufferin" rel="nofollow">ing. This is Correspondence susan.strin" rel="nofollow">in[email protected] Susan Strin" rel="nofollow">inger is Macmillan head and neck nurse specialist, Sherwood Forest Hospitals NHS Trust, Mansfield, Nottin" rel="nofollow">inghamshire Date of submission January 12 2013 Date of acceptance March 7 2013 Peer review This article has been subject to double-blin" rel="nofollow">ind review and checked usin" rel="nofollow">ing antiplagiarism software Author guidelin" rel="nofollow">ines www.cancernursin" rel="nofollow">ingpractice.co.uk Abstract This article aims to demonstrate the extent to which end of life care for children raises moral dilemmas. It considers a case study of an 11-year-old boy with lymphoma, examin" rel="nofollow">inin" rel="nofollow">ing the considerations of the decision-makin" rel="nofollow">ing process in" rel="nofollow">involved in" rel="nofollow">in his treatment and drawin" rel="nofollow">ing on various aspects of the scenario to illustrate and discuss different choices. Keywords Autonomy, beneficence, children, end of life care, ethical issues, justice, non-maleficence, veracity 27-32 CNP Sept 2013.in" rel="nofollow">indd 27 03.09.2013 15:51 September 2013 | Volume 12 | Number 7 CANCER NURSING PRACTICE28 Art & science | ethics endorsed by the department of Health’s (2008) End of Life Care Strategy, which recognises the many challenges faced in" rel="nofollow">in meetin" rel="nofollow">ing the needs and preferences of people approachin" rel="nofollow">ing death. difficulties are in" rel="nofollow">inevitably encountered in" rel="nofollow">in the provision of end of life care, with people’s views differin" rel="nofollow">ing significantly, so a good understandin" rel="nofollow">ing of ethical prin" rel="nofollow">inciples is imperative. Such prin" rel="nofollow">inciples provide a guide for healthcare professionals about their duty, responsibilities and conduct, and give a firm foundation on which to base their decision makin" rel="nofollow">ing. Ethics To contextualise the ethical themes raised by the case study (see panel below), it is necessary to explain" rel="nofollow">in what is meant by the term ‘ethics’. It has been described as ‘the study which arises from the human capacity to choose among values’, and is oriented to what is ‘right, fair, just or good; about what we ought to do’ (Preston 2007) or, more specifically, the ‘study of the process for determin" rel="nofollow">inin" rel="nofollow">ing the best course of action in" rel="nofollow">in the face of conflictin" rel="nofollow">ing choices’ (Rushton 2001). The oxford dictionaries (2013) defin" rel="nofollow">inition of ethics is ‘moral prin" rel="nofollow">inciples that govern a person’s behaviour or the conductin" rel="nofollow">ing of an activity’ or ‘the branch of knowledge that deals with moral prin" rel="nofollow">inciples’. It is generally held that ethical deliberation necessitates sound moral reasonin" rel="nofollow">ing to establish the best course of action (Rushton 2001, Preston 2007). However, disagreement about morality and moral views is commonplace and the literature describes several moral doctrin" rel="nofollow">ines that are now explored. Ethical relativism Ethical relativism observes that there are ‘no absolute truths in" rel="nofollow">in ethics, and that what is morally right or wrong varies from person to person or from society to society’ (Encyclopaedia Britannica 2013a). This stance contends that ‘there is no such thin" rel="nofollow">ing as what is “really” right’ (Encyclopaedia Britannica 2013a) and, in" rel="nofollow">in doin" rel="nofollow">ing so, it rationalises the capriciousness of moral belief. Similarly, Garrard (2009) alludes to the view of in" rel="nofollow">individual moral views to be right for those who believe them, even if they may not be acceptable for others. This results in" rel="nofollow">in a situation where different moral views may be held, without any bein" rel="nofollow">ing essentially amiss. However, this moral perspective does have negative implications. Garrard (2009) explain" rel="nofollow">ined that judgin" rel="nofollow">ing an action to be acceptable or unacceptable on the basis of customs or standards deemed right in" rel="nofollow">in that society leaves ‘no way of criticisin" rel="nofollow">ing people or societies who thin" rel="nofollow">ink that it’s right to harm children’, or who carry out other obviously ‘wrong’ deeds. Consequentialism This postulates that actions should be judged right or wrong on the basis of their consequences (Encyclopaedia Britannica 2013b). In other words, it is ‘morally right to do whatever will produce the best outcomes’ (Garrard 2009). However, this theory has problems; not least the potential for disagreement about what constitutes ‘good consequences’. furthermore, it upholds the view that, provided we are ‘producin" rel="nofollow">ing the best consequences, it doesn’t matter what kin" rel="nofollow">ind of thin" rel="nofollow">ings we do’ (Garrard 2009). Perhaps the most emin" rel="nofollow">inent form of consequentialism, known as utilitarianism, supports the notion that the right course of action is one that maximises overall happin" rel="nofollow">iness or wellbein" rel="nofollow">ing to the greatest number of people (Garrard 2009). The question arises then for those who support Case study Josh (not his real name) was an 11-year-old boy with lymphoma who relapsed after prolonged periods of hospitalisation as a consequence of his condition and the side effects from chemotherapy treatment. After an in" rel="nofollow">initial cycle of chemotherapy, Josh underwent further in" rel="nofollow">investigations, which confirmed that his cancer had returned. He went on to have further chemotherapy treatment, but was excluded from the decision-makin" rel="nofollow">ing process that led to this decision. The decision to give further treatment was made by Josh’s clin" rel="nofollow">inical team, with the consent of his parents. The treatment was unsuccessful, but this fact was withheld from him until he had worked it out for himself. When he realised that he was in" rel="nofollow">in the palliative stage of his disease trajectory, Josh thought that he had been denied the opportunity to express his opin" rel="nofollow">inions and feelin" rel="nofollow">ings about the situation. This secrecy in" rel="nofollow">initially in" rel="nofollow">induced feelin" rel="nofollow">ings of confusion, anger and betrayal in" rel="nofollow">in Josh, and overshadowed his relationship with his medical team and his parents. However, subsequently, when they were all aware of the situation, it allowed them to talk openly. 27-32 CNP Sept 2013.in" rel="nofollow">indd 28 03.09.2013 15:51 CANCER NURSING PRACTICE September 2013 | Volume 12 | Number 7 29 the notion of consequentialism, and particularly utilitarianism, whether it is morally acceptable to treat a few people unfavourably, in" rel="nofollow">in pursuit of improvin" rel="nofollow">ing the lives of most people. Deontology deontology asserts that certain" rel="nofollow">in thin" rel="nofollow">ings should be done ‘on prin" rel="nofollow">inciple or because they are in" rel="nofollow">inherently right’; thereby accentuatin" rel="nofollow">ing the concepts of ‘obligation, ought, duty and right and wrong’ (Encyclopaedia Britannica 2013c). The values of deontologists dictate that there are specific types of acts that we should do, and others that we should not do. for example, lyin" rel="nofollow">ing, stealin" rel="nofollow">ing and killin" rel="nofollow">ing the in" rel="nofollow">innocent are forbidden, while keepin" rel="nofollow">ing promises and protectin" rel="nofollow">ing the in" rel="nofollow">innocent are required (Garrard 2009). As with the other ethical theories, deontology also has its drawbacks, and a common criticism is that because there are several rules in" rel="nofollow">in this theory, conflicts between moral duties often ensue. Choosin" rel="nofollow">ing between two moral duties may be difficult, and some situations demand in" rel="nofollow">infrin" rel="nofollow">ingement of one moral to uphold another. A further criticism is that, because deontology is based on absolutes and does not allow for grey areas, it compels people to uphold morals even when specific situations render this questionable. Absolute moral prin" rel="nofollow">inciples are often too general to deal with specific situations, and often result in" rel="nofollow">in ‘conflict of duty’. However, deontologists may overcome this by in" rel="nofollow">interpretin" rel="nofollow">ing them differently – by ‘capturin" rel="nofollow">ing moral tendencies’ as opposed to thin" rel="nofollow">inkin" rel="nofollow">ing of them as absolute and exception-less; thereby ensurin" rel="nofollow">ing that moral judgements are ‘sensitive to context’ (Garrard 2009). Four prin" rel="nofollow">inciple approach Prin" rel="nofollow">inciplism has been proposed as a form of deontology that considers the application of moral prin" rel="nofollow">inciples, as opposed to moral theory, to guide ethical decision makin" rel="nofollow">ing (Garrard 2009). A version of this, developed by Beauchamp and Childress (2009), proposed that there are four moral prin" rel="nofollow">inciples that ‘capture the core of ethical thin" rel="nofollow">inkin" rel="nofollow">ing in" rel="nofollow">in the domain" rel="nofollow">in of health care’ (Garrard 2009). This ‘four prin" rel="nofollow">inciple approach’ has become the foundation of medical ethics, and is now widely applied in" rel="nofollow">in decision makin" rel="nofollow">ing in" rel="nofollow">in health care. It assists doctors and other healthcare workers to make decisions on moral issues (Gillon 1994, Garrard 2009). The four prin" rel="nofollow">inciples are respect for autonomy, beneficence, non-maleficence and justice (Box 1). In addition to the four prin" rel="nofollow">inciples, two more values form the cornerstone of medical practice (Mohanti 2009): ¦¦ Veracity (honesty, truthfulness). ¦¦ Respect for persons (the right to dignity). The four prin" rel="nofollow">inciples approach is adaptable, and may be defensible by deontologists and consequentialists. However, one criticism of the approach is that it lacks any distin" rel="nofollow">inct method of prioritisin" rel="nofollow">ing between the prin" rel="nofollow">inciples in" rel="nofollow">in in" rel="nofollow">instances of conflict. Beauchamp and Childress (2009) accepted that ‘neither morality nor ethical theory has the resources to provide a sin" rel="nofollow">ingle solution to every moral problem’ and that these prin" rel="nofollow">inciples should be used to guide decision makin" rel="nofollow">ing. Thus there remain" rel="nofollow">ins a need for healthcare professionals to assess situations in" rel="nofollow">individually, before formulatin" rel="nofollow">ing an appropriate response. The case study (see panel, opposite page) serves to illustrate an ethical dilemma and highlights the stresses related to makin" rel="nofollow">ing difficult decisions. Beneficence and non-maleficence Balancin" rel="nofollow">ing beneficence and non-maleficence, or balancin" rel="nofollow">ing benefit with harm, is evident in" rel="nofollow">in Josh’s case, although it is acknowledged that in" rel="nofollow">in many circumstances a ‘certain" rel="nofollow">in degree of harm may be necessary to provide a benefit’ (Thorns and Garrard 2011). Although Josh’s oncologist and his parents acknowledged that the second round of chemotherapy was aggressive and his chance of cure was min" rel="nofollow">inimal, Josh was not consulted before treatment, which went ahead without him bein" rel="nofollow">ing Box 1 Four prin" rel="nofollow">inciples of medical ethics ¦¦ Respect for autonomy recognises the rights of in" rel="nofollow">individuals for self-determin" rel="nofollow">ination and is the basis for in" rel="nofollow">informed consent. This prin" rel="nofollow">inciple in" rel="nofollow">infers obligations for truth tellin" rel="nofollow">ing and refrain" rel="nofollow">inin" rel="nofollow">ing from deceit, respect for privacy and assistin" rel="nofollow">ing others to make ‘important decisions’ (Garrard 2009). ¦¦ Beneficence refers to actions that foster the welfare of others in" rel="nofollow">includin" rel="nofollow">ing ‘all forms of action in" rel="nofollow">intended to benefit other persons’ (Ashcroft et al 2007). ¦¦ Non-maleficence relates to avoidance of harm, and is considered by many to be the primary consideration (Beauchamp and Childress 2009). It is widely believed that it is more important not to harm patients, than to do them good (Ashcroft et al 2007). ¦¦ Justice denotes ‘treatin" rel="nofollow">ing people fairly’ (Garrard 2009) or distributin" rel="nofollow">ing the benefits and costs of a specific decision fairly; for example, by ‘promotin" rel="nofollow">ing the fair allocation of health care resources’ (Encyclopaedia Britannica 2013d). 27-32 CNP Sept 2013.in" rel="nofollow">indd 29 03.09.2013 15:51 September 2013 | Volume 12 | Number 7 CANCER NURSING PRACTICE30 Art & science | ethics given a choice. The hope of benefit from the treatment was ultimately deemed to justify the potential harm it would cause. The problems with this are twofold. first, it raises the question as to what may be considered a ‘reasonable burden’ and second, by whom may it be considered to be so. It is accepted that opin" rel="nofollow">inions about this may vary between the treatment team, the parents and the child (Rushton 2001); with the child in" rel="nofollow">inevitably havin" rel="nofollow">ing to bear the consequences of the disease and treatment. Thus troublin" rel="nofollow">ing questions exist – not least the threshold for the decision that treatment is unbearable, and the poin" rel="nofollow">int at which hope of benefit is deemed too slight to justify treatment. As recognised by Rushton (2001), ‘choices among treatments should benefit the in" rel="nofollow">infant or child, and clearly outweigh the associated burdens and harms’. She added the tenet that ‘prolongation of life may not always be in" rel="nofollow">in the child’s best in" rel="nofollow">interests’. In Josh’s case, it could be argued that as the medical team acknowledged that the chemotherapy was aggressive and was likely to be futile, its admin" rel="nofollow">inistration delayed his death, without any significant alleviation of sufferin" rel="nofollow">ing. Therefore, it is clear that respect for the prin" rel="nofollow">inciples of beneficence and non-maleficence becomes even more critical in" rel="nofollow">in cases where the sufferin" rel="nofollow">ing and distress elicited are likely to be disproportionate to the prospective benefit, and where the probability of a positive outcome is far from assured, as in" rel="nofollow">in Josh’s case. The prin" rel="nofollow">inciple of non-maleficence has several applications, particularly in" rel="nofollow">in relation to the ‘doctrin" rel="nofollow">ine of double effect, withholdin" rel="nofollow">ing and withdrawin" rel="nofollow">ing treatment, futility arguments and quality of life debates’ (Samanta and Samanta 2011). To justify an act of double effect, four conditions must be satisfied. These in" rel="nofollow">include the tenet that ‘in" rel="nofollow">independent of its consequences, the nature of the act must be good or at least morally neutral’, and that ‘proportionality demands that the good effect must outweigh the bad effect’ (Samanta and Samanta 2011). Thus, the decision to proceed with this burdensome treatment was justified by the hope of a beneficial outcome and potential cure. Perhaps a more balanced approach to Josh’s care would have been to in" rel="nofollow">involve him in" rel="nofollow">in the decision makin" rel="nofollow">ing, by ascertain" rel="nofollow">inin" rel="nofollow">ing and respectin" rel="nofollow">ing his wishes, in" rel="nofollow">in light of his knowledge, understandin" rel="nofollow">ing and experience of previous treatment. Respect for autonomy The second prin" rel="nofollow">inciple called in" rel="nofollow">into question by the case study is that of respect for autonomy. This doctrin" rel="nofollow">ine relates to ‘respect for persons’; reverin" rel="nofollow">ing the ‘in" rel="nofollow">individual’s right to decide upon their own destin" rel="nofollow">iny and to be in" rel="nofollow">in charge of decisions relatin" rel="nofollow">ing to themselves’ (Thorns and Garrard 2011). The implicit belief exists that the choices made by the patient, as long as he or she is competent, have primacy. It is undisputed that adults have the right to decide what they consider to be ‘in" rel="nofollow">in their best in" rel="nofollow">interests’ (Larcher 2005) and for others to be acceptin" rel="nofollow">ing of these choices; in" rel="nofollow">includin" rel="nofollow">ing the rejection of life-sustain" rel="nofollow">inin" rel="nofollow">ing medical treatments (Sulmasy and Pellegrin" rel="nofollow">ino 1999). However, to be able to formulate an autonomous decision, it is necessary for the in" rel="nofollow">individual to possess the competence to do so. Unfortunately, this decision-makin" rel="nofollow">ing process in" rel="nofollow">in the paediatric settin" rel="nofollow">ing becomes complicated, as children are often unable to grasp the complex issues in" rel="nofollow">involved (Attard-Montalto 2002). This raises the question as to what age children are able to understand, and there is no clarity on this. Vin" rel="nofollow">ince and Petros (2009) suggested that children as young as ten years old were aware of their impendin" rel="nofollow">ing death. Rushton (2001) argued that after the age of five, children have an understandin" rel="nofollow">ing of the fin" rel="nofollow">inality of death and should be provided with in" rel="nofollow">information and be in" rel="nofollow">involved in" rel="nofollow">in decisions about treatment. However, chronological age is just one factor. Rushton (2001) claimed that despite their ‘developmental immaturity and legal status as min" rel="nofollow">inors’, the philosophy of ‘respect for persons’ demands that children are acknowledged as ‘in" rel="nofollow">individuals whose thoughts, experiences, and opin" rel="nofollow">inions matter’, and emphasised the pertin" rel="nofollow">inence of in" rel="nofollow">involvin" rel="nofollow">ing children in" rel="nofollow">in decisions relatin" rel="nofollow">ing to their treatment. She attributed this opin" rel="nofollow">inion to the heightened understandin" rel="nofollow">ing of their illness and profound knowledge of the ramifications of treatments that many ill children have, and professed that in" rel="nofollow">in view of this they should be afforded ‘appropriate moral status in" rel="nofollow">in the decision-makin" rel="nofollow">ing process’. The General Medical Council (2010) asserted that the competence of a child is related not only to their developmental stage, but also to their experience. It described how a young child who has already endured two courses of chemotherapy will have ‘more in" rel="nofollow">informed views about proposals Decision makin" rel="nofollow">ing in" rel="nofollow">in the paediatric settin" rel="nofollow">ing becomes complicated, as children are often unable to grasp the complex issues in" rel="nofollow">involved 27-32 CNP Sept 2013.in" rel="nofollow">indd 30 03.09.2013 15:51 CANCER NURSING PRACTICE September 2013 | Volume 12 | Number 7 31 for a third course of treatment than adult patients who are considerin" rel="nofollow">ing such treatment for the first time’; whereas the framework of values for other children with no experience of decision makin" rel="nofollow">ing will ‘remain" rel="nofollow">in unformed’. Although children cannot be completely autonomous, their opin" rel="nofollow">inions should be considered and their views acknowledged when decisions are made about their treatment and care. In the case study, Josh’s views and opin" rel="nofollow">inions on havin" rel="nofollow">ing further treatment were overlooked, suggestin" rel="nofollow">ing lack of respect. However, it is clear that children’s capacity to understand in" rel="nofollow">information and make judgements about their treatment will vary widely. furthermore, the in" rel="nofollow">individual child’s wish for participation in" rel="nofollow">in treatment decisions may also vary, and it is recognised that capacity for makin" rel="nofollow">ing decisions about health care may depend on the situation. To illustrate this poin" rel="nofollow">int, Rushton (2001) cited the example of a child who is able to choose not to undergo further chemotherapy, but does not possess the capacity to return home to die. Therefore, the in" rel="nofollow">individual child should lead discussions on a case-by-case basis and subsequent care should be negotiated in" rel="nofollow">in a staged manner. The concepts of autonomy and respect for persons are in" rel="nofollow">inextricable from collaboration and shared decision makin" rel="nofollow">ing. To accomplish this co-creation of in" rel="nofollow">individual preferences towards the end of life and to navigate an appropriate plan for care and treatment, the patient’s values, preferences and goals must first be ascertain" rel="nofollow">ined. This approach has been championed in" rel="nofollow">in the literature as one that ensures ‘empowerment of the dyin" rel="nofollow">ing person, allowin" rel="nofollow">ing them to retain" rel="nofollow">in a sense of control until the end’ (Mak and Clin" rel="nofollow">inton 1999). However, in" rel="nofollow">in the case of children – as illustrated by Josh’s situation – this is not always easy to accomplish. Some may consider that Josh’s autonomy was unacceptably violated by burdenin" rel="nofollow">ing him with further treatment; while others may conclude that any in" rel="nofollow">infrin" rel="nofollow">ingement to Josh’s autonomy would be justified on account of the beneficial outcome and a hope of cure. Thus, the subjective component of ethical decision makin" rel="nofollow">ing is clear. In Josh’s case, it could be argued that his previous experiences and in" rel="nofollow">informed views should have been given more weight by allowin" rel="nofollow">ing him to become in" rel="nofollow">involved about decisions on his future. Veracity Although not one of the main" rel="nofollow">in four prin" rel="nofollow">inciples, veracity is an important constituent of medical ethics. To achieve active participation in" rel="nofollow">in treatment decisions, all parties need to be fully in" rel="nofollow">informed. This in" rel="nofollow">in turn relies on the ethical prin" rel="nofollow">inciple of veracity, and although lin" rel="nofollow">inked to the prin" rel="nofollow">inciple of ‘respect for persons’, it is often an issue that parents and medical professionals struggle with – as was evident in" rel="nofollow">in Josh’s case. It may be considered that withholdin" rel="nofollow">ing in" rel="nofollow">information from children is an act of deception and is paternalistic. Alternatively, protectin" rel="nofollow">ing a child from potentially distressin" rel="nofollow">ing in" rel="nofollow">information could be justified on the basis of non-maleficence (Rushton 2001). A moral tension exists when the idea of engagin" rel="nofollow">ing the child in" rel="nofollow">in decisions about treatment is balanced again" rel="nofollow">inst the fear of imposin" rel="nofollow">ing the burden of knowledge and choice on to the child. Thus conflict ensues between the desire to protect the child, and the desire to impart potentially distressin" rel="nofollow">ing in" rel="nofollow">information to him or her. In Josh’s case, the course of action chosen by his parents and oncologist in" rel="nofollow">initially denied him the chance to express his concerns, thus strain" rel="nofollow">inin" rel="nofollow">ing family relationships at a time of great need for the parent and child. This resulted in" rel="nofollow">in a position of uncertain" rel="nofollow">inty and isolation, where Josh was potentially left to deal with distressin" rel="nofollow">ing in" rel="nofollow">information on his own. In practice, veracity does not have to be polarised again" rel="nofollow">inst a good death and perhaps the most important consideration is to take thin" rel="nofollow">ings step by step, at the child’s pace. for example, it should be acknowledged that children may not wish to be party to certain" rel="nofollow">in in" rel="nofollow">information, and may at times prefer decisions to be made for them. However, the importance of ‘ongoin" rel="nofollow">ing dialogue’ is also recognised; so that children may be assured that when they request in" rel="nofollow">information it will be provided truthfully (Rushton 2001). Justice Although not a major consideration in" rel="nofollow">in this case study, the prin" rel="nofollow">inciple of justice should be mentioned. In the current climate of austerity there is a question about the moral justification of treatin" rel="nofollow">ing Josh with second-lin" rel="nofollow">ine chemotherapy with little chance of cure. Conclusion The analysis of Josh’s case study has demonstrated that despite the use of robust ethical frameworks and prin" rel="nofollow">inciples, such as the four prin" rel="nofollow">inciples approach, complex issues and ethical dilemmas Conflict ensues between the desire to protect the child, and the desire to impart potentially distressin" rel="nofollow">ing in" rel="nofollow">information to him or her 27-32 CNP Sept 2013.in" rel="nofollow">indd 31 03.09.2013 15:51 September 2013 | Volume 12 | Number 7 CANCER NURSING PRACTICE32 Art & science | ethics will be commonplace, particularly in" rel="nofollow">in ‘life or death situations’ (Attard-Montalto 2002). Thus, it is important that healthcare professionals are able to provide reasons for choosin" rel="nofollow">ing one decision over another. As professionals, nurses are ‘personally accountable for actions and omissions’ in" rel="nofollow">in their practice and ‘must always be able to justify decisions’ (nursin" rel="nofollow">ing and Midwifery Council 2008). To respond to complex and often emotive issues, nurses may improve their decision makin" rel="nofollow">ing not only by possessin" rel="nofollow">ing a comprehensive ethical knowledge, but also by havin" rel="nofollow">ing an appreciation of their own beliefs, while respectin" rel="nofollow">ing the beliefs of others. References Ahmedzai S, Costa A, Blengin" rel="nofollow">ini C et al (2004) A new in" rel="nofollow">international framework for palliative care. European Journal of Cancer. 40, 15, 2192-2200. Ashcroft R, Dawson A, Draper H et al (Eds) (2007) Prin" rel="nofollow">inciples of Health Care Ethics. Second edition. John Wiley and Sons, Chichester. Attard-Montalto S (2002) Ethical issues in" rel="nofollow">in paediatric practice – part III: issues relatin" rel="nofollow">ing to the dyin" rel="nofollow">ing process. Images in" rel="nofollow">in Paediatric Cardiology. 4, 2, 32-34. Beauchamp T, Childress J (2009) Prin" rel="nofollow">inciples of Biomedical Ethics. Sixth edition. oxford University Press, new York nY. Department of Health (2008) End of Life Care Strategy: Promotin" rel="nofollow">ing High Quality Care for all Adults at the End of Life. dH, London. Encyclopaedia Britannica (2013a) Ethical Relativism. tin" rel="nofollow">inyurl.com/britannica-ethrelativism (Last accessed: August 27 2013.) Encyclopaedia Britannica (2013b) Consequentialism. tin" rel="nofollow">inyurl.com/britannica- consequentialism (Last accessed: August 27 2013.) Encyclopaedia Britannica (2013c) Deontological Ethics. tin" rel="nofollow">inyurl.com/britannica-deontol-ethics (Last accessed: August 27 2013.) Encyclopaedia Britannica (2013d) Four Prin" rel="nofollow">inciples Approach. tin" rel="nofollow">inyurl.com/britannica- 4prin" rel="nofollow">inciples (Last accessed: August 27 2013.) Garrard E (2009) What is ethics? In Earle S, Komaromy C, Bartholomew C (Eds) Death and Dyin" rel="nofollow">ing: A Reader. Sage Publications, London. General Medical Council (2010) Treatment and Care Towards the End of Life: Good Practice in" rel="nofollow">in Decision Makin" rel="nofollow">ing. www.gmc-uk.org/End_of_life. pdf_32486688.pdf (Last accessed: July 23 2013.) Gillon R (1994) Medical ethics: four prin" rel="nofollow">inciples plus attention to scope. British Medical Journal. 309, 6948, 184-188. Larcher V (2005) Consent, competence, and confidentiality. British Medical Journal. 330, 7487, 353-356. Mak J, Clin" rel="nofollow">inton M (1999) Promotin" rel="nofollow">ing a good death: an agenda for outcomes research. A review of the literature. Nursin" rel="nofollow">ing Ethics. 6, 2, 97-106. Mohanti B (2009) Ethics in" rel="nofollow">in palliative care. Indian Journal of Palliative Care. 15, 2, 89-92. Nursin" rel="nofollow">ing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. nMC, London. Oxford Dictionaries (2013) Ethics. http:// oxforddictionaries.com/defin" rel="nofollow">inition/english/ ethics?q=ethics (Last accessed: July 19 2013.) Preston N (2007) Understandin" rel="nofollow">ing Ethics. Third edition. The federation Press, Leichhardt nSW. Royal College of Paediatrics and Child Health (2004) Witholdin" rel="nofollow">ing or Withdrawin" rel="nofollow">ing Life Sustain" rel="nofollow">inin" rel="nofollow">ing Treatment in" rel="nofollow">in Children: A Framework for Practice. Second edition. RCPCH, London. Rushton C (2001) Advocacy and moral agency: a road map for navigatin" rel="nofollow">ing ethical issues in" rel="nofollow">in pediatric critical care. In Curley M, Moloney-Harmon P (Eds) Critical Care Nursin" rel="nofollow">ing of Infants and Children. WB Saunders, Philadelphia PA. Samanta J, Samanta A (2011) Medical Law. Palgrave Macmillan, London. Sulmasy D, Pellegrin" rel="nofollow">ino E (1999) The rule of double effect: clearin" rel="nofollow">ing up the double talk. Archives of Internal Medicin" rel="nofollow">ine. 159, 6, 545-550. Thorns A, Garrard E (2011) Ethical issues in" rel="nofollow">in care of the dyin" rel="nofollow">ing. In Ellershaw J, Wilkin" rel="nofollow">inson S (Eds) Care of the Dyin" rel="nofollow">ing: A Pathway to Excellence. Second edition. oxford University Press, oxford. Vin" rel="nofollow">ince T, Petros A (2009) Should children’s autonomy be respected by tellin" rel="nofollow">ing them of their immin" rel="nofollow">inent death? In Earle S, Komaromy C, Bartholomew C (Eds) Death and Dyin" rel="nofollow">ing: A Reader. Sage Publications, London. World Health Organization (1986) Cancer Pain" rel="nofollow">in Relief. Guidelin" rel="nofollow">ines for the Management of Cancer Pain" rel="nofollow">in. WHo, Geneva. World Health Organization (1998) Cancer Pain" rel="nofollow">in Relief and Palliative Care in" rel="nofollow">in Children. WHo, Geneva. World Health Organization (2002) National Cancer Control Programmes: Policies and Managerial Guidelin" rel="nofollow">ines. Second edition. WHo, Geneva. Conflict of in" rel="nofollow">interest None declared onlin" rel="nofollow">ine archive For related in" rel="nofollow">information, visit our onlin" rel="nofollow">ine archive and search usin" rel="nofollow">ing the keywords Implications for practice ¦¦ As illustrated by this case study, in" rel="nofollow">in paediatric end of life care there is often conflict between the wish to protect a child and the need to respect their autonomy and right to be in" rel="nofollow">involved in" rel="nofollow">in discussions about their treatment. ¦¦ Although in" rel="nofollow">in some cases children prefer to let others make decisions for them, this should never be assumed, and all cases must be considered in" rel="nofollow">individually. ¦¦ The competence of a child should encompass their developmental stage and level of experience, in" rel="nofollow">in addition to chronological age. 27-32 CNP Sept 2013.in" rel="nofollow">indd 32 03.09.2013 15:51 Copyright of Cancer Nursin" rel="nofollow">ing Practice is the property of RCN Publishin" rel="nofollow">ing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may prin" rel="nofollow">int, download, or email articles for in" rel="nofollow">individual use.