[Action before ethical dilemmas in the consultation after divorce. Role of the minor according to age and level of maturity]. / Actuación ante los dilemas éticos en la consulta tras divorcio. Papel del menor según edad y nivel de madurez.

Lately, number of divorces is increasing, nevertheless, a parents' divorce can become a traumatic problem for paediatric patients. Consequently, the aim of this study was to analyze the ethical conflicts that appear in the relationship between physician/parents/son/daughter, and more specifically those that a divorce generates. A descriptive study was developed through a survey composed by 39 items. Previously, an exhaustive bibliographic analysis was carried out. Our results show that only 35% of paediatricians interviewed have been educated in bioethics although this issue is important in daily practice. Other items show that 57,5% would not cancel a pharmacological treatment in order to improve quality of life. Also, they would react against a wrong parents' decision (82,5%). They give low value to the minor`s decision (6,05%), and rarely inform exclusively to adolescents (5%). In contrast, paediatricians sometimes ask to adolescents (20%) in first place and involved them to decide in 90% of cases. Besides, there are differences in the relation with fathers and mothers, 17,5% of mothers are informed exclusively, a fact that never happens with fathers. Ethics has an intrinsic value very important in daily clinical decisions in order to respect the rules and to adapt them to the situation of every paediatric patient. When an important ethical conflict become, as a divorce is, it is essential to know who must be informed and the rights everyone has to make a decision. It is complicated to the paediatricians yet to develop 41/2002 law for Patient's autonomy.

Actuación ante los dilemas éticos en la consulta tras divorcio. Papel del menor según edad y nivel de madurez / Action before ethical dilemmas in the consultation after divorce. Role of the minor according to age and level of maturity

En los últimos años el número de divorcios ha ido aumentando, siendo en ocasiones, para el paciente pediátrico, el divorcio de sus padres un elemento traumático. Nuestro objetivo fue analizar los conflictos éticos que se producen en la relación sanitaria médico-padres-hijo y de forma más específica en niños procedentes de separación/divorcio. Se realizó un estudio descriptivo mediante una encuesta compuesta de 39 items. Previamente se realizó un análisis bibliográfico exhaustivo de artículos relacionados. Nuestros resultados muestran que solo el 35% de los pediatras ha recibido formación en bioética pese a su importancia en la práctica diaria. Sobre otras cuestiones, la mayoría (57,5%) no retiraría el tratamiento de un paciente enfermo pese a que aumentara su calidad de vida, y actuaría ante una decisión equivocada de los padres (82,5%). Dan poco valor a las decisiones del menor (6,05%), raramente informados exclusivamente (5%). En cambio, se les informa primero en un 20% de los casos y en el 90% se les implica. Respecto a los progenitores, el 17,5% de las madres son informadas en exclusiva, nunca los padres. La ética tiene un valor intrínseco muy importante en las decisiones clínicas habituales, respetándose generalmente las normas y adaptándose a la situación particular de cada niño/a. En los casos en los que hay un conflicto importante, como divorcios, es importante conocer a quién se debe informar, y qué derecho tiene cada uno a decidir. Aún resulta difícil para algunos pediatras aplicar la ley 41/2002 de Autonomía del Paciente

Lately, number of divorces is increasing, nevertheless, a parents' divorce can become a traumatic problem for paediatric patients. Consequently, the aim of this study was to analyze the ethical conflicts that appear in the relationship between physician/parents/son/daughter, and more specifically those that a divorce generates. A descriptive study was developed through a survey composed by 39 items. Previously, an exhaustive bibliographic analysis was carried out. Our results show that only 35% of paediatricians interviewed have been educated in bioethics although this issue is important in daily practice. Other items show that 57,5% would not cancel a pharmacological treatment in order to improve quality of life. Also, they would react against a wrong parents' decision (82,5%). They give low value to the minor`s decision (6,05%), and rarely inform exclusively to adolescents (5%). In contrast, paediatricians sometimes ask to adolescents (20%) in first place and involved them to decide in 90% of cases. Besides, there are differences in the relation with fathers and mothers, 17,5% of mothers are informed exclusively, a fact that never hap-pens with fathers. Ethics has an intrinsic value very important in daily clinical decisions in order to respect the rules and to adapt them to the situation of every paediatric patient. When an important ethical conflict become, as a divorce is, it is essential to know who must be informed and the rights everyone has to make a decision. It is complicated to the paediatricians yet to develop 41/2002 law for Patient's autonomy

Parents' experiences of seeking health care and encountering allegations of shaken baby syndrome: A qualitative study.

OBJECTIVES: To explore parents' experiences of seeking health care for their children and instead being accused by healthcare professionals of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT), being reported to Social Services, undergoing judiciary processing, and the impact of these events on family (dis)integration. METHODS: Design: A qualitative study based on qualitative content analysis. Participants: Twelve parents in Sweden, mothers and fathers, seeking health care for their infants, encountering allegations of SBS/AHT, losing custody of their infants, and being subjected to a judiciary process, and finally regaining custody of their children. Data collection: In-depth interviews. RESULTS: An overarching theme 'Fighting for protection of their child after being trapped by doctors' and four sub-themes were developed to reflect the parents' experiences, reactions and interpretations. The first sub-theme, 'Being accused of injuring the child', illuminated the shock experienced when seeking care and instead being accused of being a perpetrator. The second, 'Chaos and powerlessness', refers to the emotions experienced when losing custody of the child and being caught in the enforcement of legislation by the authorities. The third, ´The unified fight against the doctors' verdict´, illustrates the parents' fight for innocence, their worry for the lost child, and their support and resistance. The fourth, 'The wounded posttraumatic growth', describes the emotions, grief, panic, anxiety, and challenges in reuniting the family, but also the parents' reflections on personal growth. Unanimously, they had experienced the authorities' inability to reconsider, and expressed a deep mistrust of paediatric care. CONCLUSIONS: Being wrongly accused of child abuse and alleged SBS/AHT evoked emotions of intense stress, but parents endured because of a successful fight to regain custody of their child. However, the trauma had a long-term impact on their lives with residual posttraumatic stress symptoms and mistrust towards healthcare services and the authorities. The results provide important inferences for restoring system failures within child protection services.

Moral disengagement and willingness to behave unethically against ex-partner in a child custody dispute.

The current study examines the role of moral disengagement on the likelihood of making false allegations or retaliating against the partner in a child custody dispute. Moral disengagement strategies can be useful to explain this tendency to harm their partner in a custody dispute, because they help reduce the aversive state caused by the dissonance provoked when the ethical principles of the individual do not match their behavior. An individual that is able to lessen the negative affect anticipated before committing a transgression, would be more likely to engage in it. A sample of 1097 Spanish adults who had experienced a break up with their partner and had children participated in the study. They were evenly divided by sex and their mean age was 39.95 (SD = 8.89). They answered to a vignette depicting a child custody dispute during a break up process and answered to a series of questions regarding whether they would be willing to make false allegations or to take retaliatory action against their former partner. They also answered to questionnaires on moral disengagement and the "dark triad" of personality. Results show that moral disengagement is a significant predictor of false allegations and retaliatory action, stronger than any of the variables included in the "dark triad", and predicts willingness to harm the partner beyond the common core of dark traits. We did not find gender differences in inclination to harm the partner, although men are more prone to the use of moral disengagement strategies than women. Still, we found that the type of moral disengagement that better predicts these tendencies is different for men and women. Men significantly favored reconstrual strategies that include moral justification, advantageous comparison and euphemistic labelling, while the best predictor for women are strategies focused on the recipient, like attribution of blame or dehumanization.

So not mothers: responsibility for surrogate orphans.

The law ordinarily recognises the woman who gives birth as the mother of a child, but in certain jurisdictions, it will recognise the commissioning couple as the legal parents of a child born to a commercial surrogate. Some commissioning parents have, however, effectively abandoned the children they commission, and in such cases, commercial surrogates may find themselves facing unexpected maternal responsibility for children they had fully intended to give up. Any assumption that commercial surrogates ought to assume maternal responsibility for abandoned children runs contrary to the moral suppositions that typically govern contract surrogacy, in particular, assumptions that gestational carriers are not 'mothers' in any morally significant sense. In general, commercial gestational surrogates are almost entirely conceptualised as 'vessels'. In a moral sense, it is deeply inconsistent to expect commercial surrogates to assume maternal responsibility simply because commissioning parents abandon children for one reason or another. We identify several instances of child abandonment and discuss their implications with regard to the moral conceptualisation of commercial gestational surrogates. We conclude that if gestational surrogates are to remain conceptualised as mere vessels, they should not be expected to assume responsibility for children abandoned by commissioning parents, not even the limited responsibility of giving them up for adoption or surrendering them to the state.

Ethical concerns for maternal surrogacy and reproductive tourism.

Reproductive medical tourism is by some accounts a multibillion dollar industry globally. The seeking by clients in high income nations of surrogate mothers in low income nations, particularly India, presents a set of largely unexamined ethical challenges. In this paper, eight such challenges are elucidated to spur discussion and eventual policy development towards protecting the rights and health of vulnerable women of the Global South.

Practice parameter for child and adolescent forensic evaluations.

This Parameter addresses the key concepts that differentiate the forensic evaluation of children and adolescents from a clinical assessment. There are ethical issues unique to the forensic evaluation, because the forensic evaluator's duty is to the person, court, or agency requesting the evaluation, rather than to the patient. The forensic evaluator clarifies the legal questions to be answered and structures the evaluation to address those issues. The forensic examination may include a review of collateral information, interviews and other assessments of the child or adolescent, and interviews with other relevant informants. The principles in this Parameter suggest the general approach to the forensic evaluation of children and adolescents and are relevant to delinquency, child custody, child maltreatment, personal injury, and other court-ordered and noncourt-ordered evaluations.

The role of the child and adolescent psychiatrist on health care institutional ethics committees.

Over the past 30 years, institutional ethics committees have become the standard vehicle for addressing ethical issues in health care institutions. Early in this development, general psychiatrists became integrally involved; however, child and adolescent psychiatry roles on institutional ethics committees have been delineated less clearly. This article provides an overview of the functioning of institutional ethics committees, including composition and a definition of the roles across education, policy development, and case consultation. Within the context of the various roles of the institutional ethics committee, the potential contributions of a child and adolescent psychiatrist are defined and specific areas of expertise are delineated. Case examples are cited to demonstrate the unique contributions in the areas of developmental understanding, enhanced understanding of communication styles and failures, as well as an understanding of specific psychiatric factors and cultural issues that a child and adolescent psychiatrist may bring to the institutional ethics committee.

Consent and participation: ethical issues in the treatment of children in out-of-home care.

Mental health service (MHS) providers confront questions of informed consent for evaluation and treatment of children in state custody who are placed in residential or foster care programs, where legal responsibility is shared between state and parent. There are ethical issues encountered by MHS providers who work with this growing population of children in placement. Matters of informed consent and access to information about treatment influence relationships with the parents, legal guardians, Child Protective Service workers, and the child. These specific concerns are addressed: informed consent, the right to be informed, and the rights of parents or foster carers to participate in a child's treatment. Recommendations for resolving dilemmas faced by MHS providers are discussed.

When agreeing with the patient is not enough: a schizophrenic woman requests pregnancy termination.

In this article, we discuss the ethical dilemma health care providers faced when Rebecca, a pregnant schizophrenic patient who lacked decision-making capacity, inconsistently requested elective pregnancy termination. When a patient's decision-making capacity is severely impaired, how does the physician balance obligations to protect the patient from harm (beneficence) while also respecting her reproductive preferences and decisions (respect for autonomy)? Rebecca suffers from polysubstance abuse and paranoid schizophrenia characterized by disorganized thought and speech, auditory hallucinations, and delusional ideas. She arrived 14+ weeks pregnant and unaccompanied at an obstetric clinic requesting an abortion. This is her second and final request. On all prior and subsequent occasions, she was either ambivalent or said she wanted to continue the pregnancy. After the consulting psychiatrist determined that she lacked decision-making capacity, steps were taken to address ethical and clinical issues. The steps included treating her schizophrenia to see if she could regain decision-making capacity; identifying a surrogate and using a shared decision-making model; and devising strategies to protect Rebecca and her fetus without resorting to excessive paternalism. Rebecca continued her pregnancy. Due to poor adherence to medical regimen and inadequate social support, Rebecca's schizophrenia was poorly controlled and she continued to use drugs during the pregnancy. She delivered a term baby who was soon removed from her custody. Despite some people's desire to protect Rebecca by complying with her request for abortion, we conclude that to do so would be ethically unjustified. To treat a decisionally impaired patient's requests for abortion as autonomous is disrespectful of the vulnerable patient because such paternalism fails to respect the patient's liberty and the surrogate's authority.

Parental refusals of medical treatment: the harm principle as threshold for state intervention.

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent's refusal to provide consent for a child's medical care. In this paper, I will argue that the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent's decision to refuse medical care on behalf of a child.