n Feature Article
Moral Dilemmas in Pediatric Orthopedics
John J. Mercuri, MD, MA; Jonathan M. Vigdorchik, MD; Norman Y. Otsuka, MD
abstract
All orthopedic surgeons face moral dilemmas on a regular basis; however, little has
been written about the moral dilemmas that are encountered when providing orthopedic care to pediatric patients and their families. This article aims to provide
surgeons with a better understanding of how bioethics and professionalism apply to
the care of their pediatric patients. First, several foundational concepts of both bioethics and professionalism are summarized, and definitions are offered for 16 important
terms within the disciplines. Next, some of the unique aspects of pediatric orthopedics as a subspecialty are reviewed before engaging in a discussion of 5 common
moral dilemmas within the field. Those dilemmas include the following: (1) obtaining
informed consent and assent for either surgery or research from pediatric patients and
their families; (2) performing cosmetic surgery on pediatric patients; (3) caring for
pediatric patients with cognitive or physical impairments; (4) caring for injured pediatric athletes; and (5) meeting the demand for pediatric orthopedic care in the United
States. Pertinent considerations are reviewed for each of these 5 moral dilemmas,
thereby better preparing surgeons for principled moral decision making in their own
practices. Each of these dilemmas is inherently complex with few straightforward
answers; however, orthopedic surgeons have an obligation to take the lead and better
define these kinds of difficult issues within their field. The lives of pediatric patients
and their families will be immeasurably improved as a result. [Orthopedics. 2015;
38(12):e1133-e1138.]
The authors are from the Hospital for Joint Diseases (JJM, JMV), NYU Langone Medical Center,
New York; and The Children’s Hospital at Montefiore (NYO), Montefiore Medical Center, Bronx, New
York.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: John J. Mercuri, MD, MA, Hospital for Joint Diseases,
NYU Langone Medical Center, 301 E 17th St, Rm 1402, New York, NY 10003 (john.mercuri@nyumc.
org).
Received: March 23, 2015; Accepted: May 4, 2015.
doi: 10.3928/01477447-20151123-04
DECEMBER 2015 | Volume 38 • Number 12
e1133
n Feature Article
O
rthopedists regularly face moral
dilemmas, especially when treating children. This article aims to
provide surgeons with a better understanding of how bioethics and professionalism
apply to the care of pediatric patients. The
foundational concepts of bioethics and
professionalism are discussed and then
5 common moral dilemmas within the
field of pediatric orthopedics are reviewed
(Table 1).
Bioethics
Philosophy derives from the Greek
words for love (philos) and wisdom
(sophia). Philosophy involves discernment about fundamental aspects of human
existence, such as moral or ethical behavior. The word moral derives from the Latin
word mores, or the characteristic customs
or conventions of a community. The word
ethics (Greek, ethos) translates as nature,
disposition, or customs. There is no true
distinction between the terms; however,
ethics colloquially describes moral behavior within a specific discipline. Bioethics
(Greek, bios) involves moral behavior as
it relates to the biosphere. The biosphere
encompasses all living creatures and the
environment in which they live. However,
colloquial use of the term bioethics refers
to medical ethics, or the application of
moral principles to health care.
A moral principle is an ideal upon
which all conventions, norms, rules, laws,
and behaviors should be based.1,2 There
are 4 foundational moral principles in
bioethics: autonomy, beneficence, nonmaleficence, and justice.3 In recent years,
many have added confidentiality as a fifth
principle to recognize the high social value placed on health care privacy, as embodied by the Health Insurance Portability
and Accountability Act.4,5
Autonomy focuses on respect for the
patient, and it is defined as the right or interest of patients to make well-informed
decisions that define their own lives for
themselves, according to their own values
and conception of a good life, and in dia-
e1134
Table 1
Important Terms in Bioethics
Term
Definition
Philosophy
Discernment about fundamental aspects of human existence,
such as moral or ethical behavior
Morals
The characteristic customs or conventions of a community
Ethics
Nature, disposition, or customs
Bioethics
Moral behavior as it relates to the biosphere, or all living creatures and the environment in which they live
Medical ethics
The application of moral principles to health care
Moral principle
An ideal upon which conventions, norms, rules, laws, and
behaviors should be based
Autonomy
The right or interest of patients to make well-informed decisions
that define their own lives for themselves, according to their
own values and conception of a good life, and in dialogue
with their particular society
Beneficence
Physicians are obligated to do good and promote good
Nonmaleficence
Physicians are obligated to avoid inflicting evil or harm
Justice
A duty to provide society’s members with access to an adequate
level of health care that fulfills basic needs
Confidentiality
Physicians have a duty to protect a patient’s health care information
Professionalism
Commitment to and accountability for publicly declared ideals;
a promise to help vulnerable populations, appreciate and
engage cultural differences and diversity, and be experts in a
field; the responsibility to educate and self-regulate
Surrogate decision
making
A surrogate makes health care decisions for a dependent patient
Paternalism
The physician or parent acts against the will of the child and
is motivated by a claim that the child will be better off or
protected from harm
Utilitarianism
The morally correct action is the one that produces the greatest
good for the greatest number
Deontology
The morally correct action obeys a duty or obligation
logue with their particular society.4,6,7 Beneficence states that the physician is obligated to do good and promote good for
the patient. Nonmaleficence states that the
physician ought not inflict evil or harm on
the patient, and it is often quoted within
the medical profession as the Latin phrase
primum non nocere: “first, do no harm.”3,8
Justice states that society has a duty to
provide its members with access to an adequate level of health care that fulfills basic needs.4 It has a utilitarian component
that stresses maximal benefit to both patients and society and an egalitarian component that emphasizes equal rights to all
patients. Finally, confidentiality states that
physicians have a duty to protect a patient’s health care information.5
Professionalism
Professionalism is a necessary component of moral behavior and derives from
the Latin verb profiteri (to declare publicly).9 Professionalism is a personal quality and an active behavior. Professionals
publicly declare the ideals to which they
commit themselves and expect the public to hold them accountable for meeting
those ideals. Primary among those ideals
are moral principles. Professionals also
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n Feature Article
make a public promise to help vulnerable populations, appreciate and engage
cultural differences and diversity, and be
experts in their field. Professionals are
subsequently entrusted by the public with
the responsibility to educate and selfregulate their members.10-13 This synthetic
description captures many of the intangible aspects of professionalism. The Accreditation Council on Graduate Medical
Education (ACGME) defines professional
resident physicians more analytically as
those who display compassion, integrity,
respect for others, sensitivity and responsiveness to diverse patient populations,
respect and adherence to relevant ethical
principles, and responsiveness to patients
that supersedes self-interest.14
Pediatric Orthopedics
Children are morally unique because
they lack fully developed autonomy. To
have moral autonomy, one must display
4 widely accepted characteristics: capacity to understand information, capacity to
communicate a choice, ability to use information in a process of reasoning and
deliberation, and ability to compare the
consequences of alternative choices or
courses of action.6 Not all children meet
these criteria, especially younger children.
Furthermore, pediatric patients cared for
by orthopedics are often cognitively or
physically impaired. Traditional dilemmas involving patients with impairments
have added levels of complexity, and children with impairments may never achieve
moral autonomy. Thus, surgeons regularly
encounter both surrogate decision making
and paternalism.
Surrogate decision making occurs
when a surrogate makes health care decisions for a dependent patient. It relies
heavily on the principles of beneficence
and nonmaleficence and can be formulated in 1 of 3 ways: first, the surrogate
might be charged with acting in the best
interests of the patient; second, the surrogate might make decisions based on the
known values, preferences, and concerns
DECEMBER 2015 | Volume 38 • Number 12
of the patient; third, the surrogate might
be held to decision making that any other
reasonable person would agree with.15 Paternalism (Latin, pater) can describe the
actions of both the parents and physicians.
Paternalism occurs when the physician or
parent acts against the will of the child
and is motivated by a claim that the child
will be better off or protected from harm.
Consent and Assent
Consent is a process by which legally
binding permission enables a health care
event. In orthopedics, this event is often a
surgical procedure. Only a person of legal
age may provide consent. For children, a
parent or legal guardian provides consent.
In contrast, assent is an expression of approval or agreement provided by someone
younger than legal age.16 Federal regulation requires assent from minors who are
subjects in medical research.17 A written
assent document provides children with
information that they can take home with
them; signing the documents allows children to feel that their decision matters, and
including children in the process enhances
respect for their developing autonomy.18
It might appear that these different
standards create a logical non sequitur
(Latin; it does not follow). Surgeons require consent of the guardian or parent
before operating on a child. The assumptions are that children do not have the ability to make autonomous decisions about
their care or to understand what is best for
them. However, medical research requires
the assent of the child. The assumptions
are that children have at least some ability to make autonomous decisions and to
understand to some degree what is best for
them. It also assumes that children understand what is best for society at large because medical research primarily aims to
provide good for future patients.
It is necessary to recognize that research participation is optional and that
declining to participate in research may
not have any negative consequences. In
contrast, surgical care has a presumed
direct benefit to the patient and negative
consequences in its absence. A higher
standard—requiring assent for medical
research—is therefore reasonable (Table
2). Moreover, many children possess the
capacities necessary for moral autonomy,
especially adolescents. It would be disrespectful to forego assent for research participation because assent respects the developing autonomy of the child subject.19
Of course, it is important to remember
that assent is a disingenuous ethical protocol that carries no moral consequence
for children who do not demonstrate the
capacities necessary for moral autonomy.
Thus, the surgeon is obligated to assess
whether the child possesses moral autonomy before obtaining assent, regardless of
the child’s numerical age.
One may also argue that a child should
provide assent for surgical procedures.
This is most reasonable for nonemergent or
nonurgent procedures in adolescents. Legal
age is arbitrarily defined, and it is disrespectful to morally autonomous children to
forego their assent preoperatively. Surgical
assent should follow a developmental approach wherein the surgeon seeks affirmation in younger children but the equivalent
of informed consent in mature teenagers.16,19 The major concern with requiring
assent for surgery is addressing a child’s
dissent to a necessary procedure. However,
this scenario is not unprecedented. Ethics
committees and judges often overrule the
misguided decisions of patients who present a danger to themselves or others. Similar mechanisms can be used for misguided
child dissents.
Cosmetic Surgery
A wide spectrum of disparate cosmetic
procedures exists within the orthopedic
care of children. Social functioning and
emotional pain may be improved by cosmetic surgery, and these procedures are
greatly appreciated by the patient. Surgeons may adopt a cost-benefit approach
to decision making in these cases. The
perceived benefit to the patient’s quality of
e1135
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Table 2
Example Cases
Moral Dilemma
Case
Consent and assent
A major medical center is conducting a study on pediatric bone
tumors, and the research team is collecting postoperative tissue samples. The parents of a 10-year-old boy consent to the
surgical removal of an osteochondroma that is compressing
his peroneal nerve, and they also consent to the inclusion of
the excised tumor for the researcher’s tissue bank. The child,
however, refuses to assent to the inclusion of his bone in the
tissue bank, and the bone is discarded after the operation.
Cosmetic surgery
A 15-year-old girl with a congenitally foreshortened second
metatarsal desires a longer toe so she can wear sandals in
the summer without being teased by her peers. The parents
support their daughter, and after a lengthy discussion of the
risks and benefits, the parents provide consent for the surgery.
Three weeks postoperatively, the external fixator pin sites
become infected and require operative debridement. The infection tracts down to the osteotomy site. The patient requires
extended antibiotic therapy.
Impaired children
A child with advanced scoliosis also has an unspecified cardiomyopathy that was declared recalcitrant to medical management several years ago. After consulting multiple orthopedists
across many hospital centers, the parents are unable to find a
surgeon who feels comfortable attempting the procedure due
to the cardiomyopathy. The child then sees a new cardiologist
who offers a different diagnosis of the heart condition and an
alternative approach to treatment. This alternative approach
significantly improves the child’s cardiac function, and a new
surgeon agrees to proceed with the surgery.
Pediatric athletes
A 16-year-old soccer player tears her anterior cruciate ligament
while playing in a summer soccer league. She is a top player
in the state, and her upcoming fall season is in jeopardy. She
is starting her junior year of high school, and it is important
for her to have a strong season to demonstrate her skills to
college recruiters. An orthopedist reconstructs her anterior
cruciate ligament, and the patient is now progressing through
the rehab protocol. The patient and the family want to accelerate the rehabilitation protocol so that she can return to play
as quickly as possible and salvage her season. Their desired
rehabilitation time line is faster than what the surgeon feels
comfortable with, and the risk of re-injury is high.
Meeting demand for
care
A large region of a Midwestern state does not have any practicing pediatric orthopedists. The general orthopedists had been
treating pediatric conditions for many years as part of their
practices to meet the demand for care. As the senior generalists retire, younger orthopedists move into the area to practice.
However, the younger surgeons are not fellowship trained in
pediatrics and feel uncomfortable caring for pediatric patients.
The closest metropolitan area with a pediatric orthopedist is a
2-hour drive away.
life must be weighed against the potential
risks of a surgical intervention (Table 2).
One must consider whether the procedure
must be performed during childhood or
whether it can be postponed until the child
reaches consenting age. Cosmetic procedures should only be performed if there is a
e1136
medical benefit or necessity to performing
the procedure during childhood.
Adolescence is a time of psychosocial
development and emotional angst. Adolescents are at a high risk for poor decision making regarding physical appearance. Both patients and their parents must
understand the value assumptions that
underlie any decision to alter one’s physical appearance. These values differ widely
across cultures.13 The surgeon is obligated
to consider the personal identity formation of the patient along with an assessment of autonomy to make such a decision.20 The surgeon should understand the
autobiographical life narrative that is being written by the child at a level of detail
beyond what is required for noncosmetic
treatments.21
When considering cosmetic surgery,
distinctions must be made between restorative and enhancing procedures, as well as
normalizing and marginalizing interventions.22 Orthopedists must carefully define
what it means for their patients to be sick
or well. Likewise, a normal patient must
be distinguished from a marginal patient.
Posttraumatic limb lengthening is clearly
restorative to a patient who has experienced
bone loss. However, lengthening the functional limbs of an individual with dwarfism
may be enhancing anatomy beyond what is
necessary for activities of daily living. At
the same time, lengthening the extremities of an individual with dwarfism might
be viewed as normalizing the patient with
dwarfism to the non-dwarf majority.
Children With Impairments
Orthopedists regularly care for children
who are physically and cognitively impaired. Questions arise about the qualities
and characteristics that confer moral status.23 Are children with impairments worthy of moral consideration because they are
Homo sapiens or because they share DNA
sequences, possess sentience, express emotions, or have families?24,25 Do some lack
moral status because of an absence of Aristotelian telos, nous, or phronesis (Greek;
purpose, reason, and practical wisdom).26,27
These are some of the biggest questions
within moral philosophy, and they will not
be easily answered by orthopedists.
However, orthopedists will face questions of resource utilization regarding
children with impairments. There are 2
Copyright © SLACK Incorporated
n Feature Article
broad approaches to consider. The first is
consequentialism, widely understood as
utilitarianism. The morally correct utilitarian action is the one that produces the
greatest good for the greatest number.28
This is the dominant approach used in
Western health care. All variables that
impact the outcome are identified, valued,
and summed. The impairment of a child is
debatable as a positive or negative variable
in the calculus, but it is only one variable
among many. In contrast, the other major
approach is nonconsequentialism, most
commonly understood as deontology.11 In
this framework, the moral agents have duties or obligations to act in ways that may
not maximize utility. For example, the
social contract of a morally just society
might demand equal access to treatment
for all patients, regardless of impairment,
and that physicians have a moral obligation to treat all patients equally.
Two cognitive biases commonly arise
when discussing children with impairments. First, impairment bias is a subconscious discrimination against physically
or mentally impaired individuals based
simply on their impairments.29 This bias
may lead one to assign an excessive negative value to the patient’s impairment in a
consequentialist calculus. Second, anchor
bias is a subconscious over-reliance on
one piece of salient information in a clinical scenario.30 This bias may subsequently
lead one to ignore other important pieces
of information or alternative treatment possibilities (Table 2). Anchor bias is a common cognitive hazard in all of medicine,
but it is especially acute in scenarios where
impairment is a major piece of salient information. The surgeon must be careful to
avoid these biases. As with all patients, the
surgeon must remain focused on providing
high-quality care for children with impairments as guided by principled moral decision making.
Pediatric Athletes
As many as 21.5 million children between the ages of 6 and 17 years par-
DECEMBER 2015 | Volume 38 • Number 12
ticipate in organized team athletics in the
United States.31 Child athletes sustain injuries ranging from strains and sprains to
fractures and ligament tears. Roughly 2.7
million children younger than 19 years
were treated for sports related injuries from
2001-2009, with approximately 70% of
these occurring in children between ages
10 and 19 years.32 In professional athletics, there is a triad of conflicting interests
comprised of the surgeon, the athlete, and
the team. The goals of the athlete and team
are often focused on athletic performance
and success, whereas the goals of the surgeon are focused on the long-term health of
the athlete.33 Pediatric athletics are further
complicated by the interests of the parents,
thereby creating a quadrad of conflict.34
The principles of beneficence and
nonmaleficence are paramount. The surgeon is obligated to align all parties with
the best interests of the child. In some
cases, the surgeon must assume a paternalistic role to achieve this goal. Pediatric athletes are at high risk for poor decision making (Table 2). It is difficult to
maintain perspective beyond the game
or season at hand, and the rewards for a
quick return to play are alluring. It is important for the surgeon to understand the
patient’s entire athletic narrative. Taking extra time to build a strong surgeonpatient rapport will enhance the athlete’s
compliance.
Meeting Demand for Care
A discrepancy exists between the pediatric orthopedic workforce and the demand
for care. Approximately 3% of practicing
orthopedists are fellowship trained, and
anywhere from 3% to 8% of current residents are choosing to enter pediatric fellowships.35,36 It is estimated that 20 to 25
graduating fellows are needed each year
to maintain the current workforce levels.35
However, about 35 per year may be needed to meet future demand.37 Demand is increasing not only from population growth,
but also from shifting practice models.
Orthopedists in community settings face
disincentives to care for pediatric trauma
and musculoskeletal infection.35 Reasons
for this include an adverse reimbursement
mix and a lengthy period of malpractice
liability.37 As a result, trauma and infection volume are increasing for pediatric
fellowship-trained surgeons.38
The principle of justice dictates that the
health care system has a duty to provide an
adequate pediatric orthopedic care that fulfills basic needs. An orthopedist who takes
emergency call is thereby obligated to care
for the basic needs of pediatric patients (Table 2). The basics of pediatric orthopedics
are debatable and need definition by leaders
within the field. The ACGME milestones
competency project has proposed that supracondylar humerus fractures and septic
hips are foundational areas of pediatric orthopedics in which all graduating residents
must show competency.14 From this starting point, training programs have a duty
to ensure that all graduating residents can
provide basic pediatric orthopedic care as a
professional service to the community.
Conclusion
Orthopedists regularly face moral dilemmas, especially when caring for children. This article reviewed the pertinent
considerations for 5 moral dilemmas in
pediatric orthopedics, thereby providing
surgeons with a better understanding of
how bioethics and professionalism apply
to the care of pediatric patients. Moral
dilemmas are inherently complex, and
orthopedists have an obligation to address
these issues. The lives of pediatric patients
will be improved as a result.
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