Análise ética dos impactos da pandemia de COVID-19 na saúde de crianças e adolescentes / An ethical analysis of the impacts of the COVID-19 pandemic on the health of children and adolescents / Análisis ético acerca dos impactos de la pandemia COVID-19 en la salud de niños y adolescentes

A pandemia de COVID-19 trouxe impactos significativos para a vida de crianças e adolescentes em todo o mundo. Considerando esse contexto, o objetivo deste artigo foi examinar como as crianças e os adolescentes no Brasil foram impactados pela pandemia à luz de uma análise ética. Para tanto, uma análise interpretativa de estudos brasileiros sobre a saúde da criança e do adolescente durante a pandemia foi realizada. A tarefa de reconhecer essa dimensão ética é importante para entender como as respostas a situações de crise, tais como a presente situação da pandemia de COVID-19, podem ser moldadas e identificar quais as prioridades de ação de acordo com todas as partes interessadas, situando a criança entre essas partes de interesse. A análise demonstrou que tanto os efeitos diretos quanto os indiretos implicam em processos de tomada de decisão que precisam utilizar e sustentar o direito de participação da criança para que a ação tomada esteja o máximo possível focada nos melhores interesses da criança. Contudo, a realidade brasileira tem demonstrado uma exclusão estrutural das vozes infantis. Recomenda-se que mais estudos sejam conduzidos a fim de aprofundar o conhecimento sobre os melhores interesses das crianças e sua participação nas ações tomadas durante a pandemia

The COVID-19 pandemic has impacted the lives of children and adolescents around the world. This article aims to examine how the pandemic has impacted children and adolescents in Brazil using an ethical analysis. An interpretive analysis of Brazilian studies on child and adolescent health during the pandemic was conducted. The task of recognizing this ethical dimension is important to understand how responses to crisis situations, such as the current situation of the COVID-19 pandemic, can be shaped and where are the priorities for action according to all stakeholders, situating the child between these parts of interest. Our analysis highlighted both direct and indirect effects surrounding the decision-making processes for children in the COVID-19 pandemic reality. These decisional processes must sustain the child's right to participation to ascertain that the action taken is in the child's best interests. However, Brazilian reality has shown a structural exclusion of children's voices in decisions that affect them, particularly related to the effects of the pandemics in their lives. More studies must be conducted to deepen the knowledge about children's best interests and their participation in actions planning during the pandemic

La pandemia de COVID-19 ha afectado las vidas de niños y adolescentes de todo el mundo. Este artículo tiene como objetivo examinar cómo la pandemia ha afectado a los niños y adolescentes en Brasil mediante un análisis ético. Se realizó un análisis interpretativo de los estudios brasileños sobre salud del niño y del adolescente durante la pandemia. La tarea de reconocer esta dimensión ética es importante para entender cómo las respuestas a situaciones de crisis, como la situación actual de la pandemia COVID-19, pueden configurarse y dónde están las prioridades de acción según todos los actores, situando al niño entre estas partes. de interés. Estos procesos de decisión deben sustentar el derecho del niño a la participación para asegurarse de que las medidas tomadas respondan al interés superior del niño. Sin embargo, la realidad brasileña ha mostrado una exclusión estructural de las voces de los niños en las decisiones que los afectan, particularmente en relación con los efectos de las pandemias en sus vidas. Se deben realizar más estudios para profundizar el conocimiento sobre el interés superior de los niños y su participación en la planificación de acciones durante la pandemia

Involuntary psychiatric hospitalization of children and adolescents in Northern Greece: Retrospective epidemiological study and related ethical issues.

The aim of the present study was to investigate epidemiological data on involuntary hospitalization of underage patients in psychiatric settings and illustrate the related ethical issues. The medical records of 131 involuntary psychiatric admissions of children and adolescents ordered by public prosecutor between 2005 and 2014 were examined carefully. The examined variables involved the place of origin, the place of residence of minors after discharge, the length of stay in hospitals, the discharge diagnosis, the rate at which the minors were introduced to police and other authorities before their hospitalization, and the results of the neuropsychological assessment (WISC II). Data were analyzed by SPSS (Statistical Package for the Social Sciences). The mean age of the minors was 14.19 years (Male: Female ratio; 1.6:1). First, a high rate of incidences of compulsory admissions was found [5-year period (2005-2009):(2010-2014) ratio; 1:1.85] most likely due to organizational factors, which, however, could have been avoided in a more patient-oriented healthcare system. It is most likely that the criteria used for making decisions in favor of compulsory admissions were disproportionately (unduly) broad. In parallel, it was observed that, during 2010-2014, despite the increase in the rate of the prosecutor's orders, there was a decrease in the duration of coercive hospitalization of minors in psychiatric departments of hospitals in comparison to the period 2005-2009 [5-year period duration of hospitalization (2005-2009):(2010-2014) ratio; 2.33:1]. Furthermore, family was found likely to wield considerable influence on the decision-making for compulsory admissions. In addition, the effectiveness of a compulsory hospitalization of minors in a child and adolescent psychiatry department was found largely dependent on the type of the underlying mental health problem. In that respect, low rates of recidivism (7.6%) indicated that the measure of involuntary hospitalization was necessary and effective. It was also observed that the short-term removal of the minor from the family environment was a potentially relieving strategy for both the child and the family apart from the need for therapeutic intervention. The paper concludes by highlighting the role of a multi-stakeholder decision-making process (which entails shared decision-making as an integral component of providing mental healthcare to minors) in facilitating a decision about involuntary psychiatric hospitalization that is proportional and respectful to patient autonomy.

O feto e o recém-nascido com condições genéticas e congênitas graves: aspectos bioéticos e jurídicos no Brasil / El feto y el recién nacido con condiciones genéticas y congénitas graves: aspectos bioéticos y jurídicos en Brasil / Fetus and newborn with genetic and congenital severe conditions: bioethical and legal aspects in Brazil / El fetus I el nadó amb condicions genètiques I congènites greus: aspectes bioètics I jurídics a Brasil

O diagnóstico seguro de malformações congênitas possibilitado pelo avanço tecnológico da propedêutica fetal possibilita o exercício da autonomia reprodutiva da gestante, embora suscite dilemas éticos e jurídicos de difícil solução, como a opção pelo aborto e a tomada de decisões em neonatos com escassas possibilidades de sobrevivência. As decisões em fim de vida e o abandono de técnicas terapêuticas fúteis que não alteram o curso natural da doença despertam conflitos éticos entre a equipe de saúde e os familiares. Nesse cenário, importa analisar o âmbito de proteção aos direitos das pessoas com deficiência no Brasil e sua aplicação aos neonatos com graves malformações congênitas, visando contribuir ao debate sobre a morte digna no período neonatal

El diagnóstico efectivo de malformaciones congénitas que resulta del avance tecnológico de la propedéutica fetal posibilita el ejercicio de la autonomía reproductiva de la mujer embarazada, aunque presente dilemas éticos y jurídicos de solución difícil, como la opción por el aborto y la toma de decisiones en casos de recién nacidos con baja posibilidad de sobrevivir. Decisiones de fin de la vida y el abandono de técnicas terapéuticas fútiles que no cambian la evolución natural de la enfermedad producen conflictos éticos entre el equipo de salud y la familia. En ese escenario, es importante analizar el ámbito de protección a los derechos de las personas con deficiencia en Brasil y su aplicación a los recién nacidos con malformaciones congénitas graves, con el objetivo de contribuir al debate sobre la muerte digna en el periodo neonatal

The diagnostic certainty of congenital malformations, made possible by the technological advances in fetal propaedeutics, enables the exercise of reproductive autonomy by the pregnant woman, although it results in ethical and legal dilemmas that are difficult to solve, such as the option for abortion, and decision-making regarding newborns with meager survival possibility. End-of-life decisions and the abandonment of futile therapeutic techniques that do not alter the natural course of the illness give rise to ethical conflicts between the health team and family members. In this setting, it is important to analyze the scope of protection of the rights of handicapped persons in Brazil, and how it applies to the newborn with severe congenital malformations, with the goal of contributing to dignified death in the neonatal period

El diagnòstic efectiu de malformacions congènites que resulta de l'avanç tecnològic de la propedèutica fetal possibilita l'exercici de l'autonomia reproductiva de la dona embarassada, encara que presenta dilemes ètics I jurídics de solució difícil, com l'opció per l'avortament I la presa de decisions en casos de nounats amb baixa possibilitat de sobreviure. Les decisions de final de la vida I l'abandonament de tècniques terapèutiques fútils que no canvien l'evolució natural de la malaltia donen lloc a conflictes ètics entre l'equip de salut I la família. En aquest escenari, és important analitzar l'àmbit de protecció dels drets de les persones amb deficiència a Brasil I la seva aplicació als nadons amb malformacions congènites greus, a fi de contribuir al debat sobre la mort digna en el període neonatal

A imunização de crianças no Brasil: Panorama jurídico e reflexão bioética / La inmunización de niños en Brasil: Panorama jurídico y reflexión bioética / The immunization of children in Brazil: Legal overview and bioethical análysis / La immunització de nens al Brasil: Panorama jurídic i reflexió bioètica

O objetivo deste artigo é analisar os aspectos jurídicos e bioéticos da vacinação obrigatória de crianças brasileiras. Primeiro, apresentamos a vacinação como um dever decorrente do direito fundamental à saúde de crianças. Depois, realiza-se uma discussão bioética sobre o citado dever jurídico, abordando os principais problemas bioéticos envolvendo a vacinação, com destaque para os eventos adversos pós-vacinação. Concluímos que a Bioética não se propõe a estabelecer normas coercitivas, mas que ela contribui para a solução dos conflitos morais identificados em cada caso concreto ao oferecer parâmetros. Já o direito brasileiro busca assegurar o direito à saúde em sua dimensão coletiva ao estabelecer a obrigatoriedade da imunização para as crianças

El objetivo de este artículo es analizar los aspectos jurídicos y bioéticos de la vacunación de niños brasileños. En primer lugar, presentamos la vacunación como un deber derivado del derecho fundamental a la salud de los niños. Después, se realiza una discusión bioética sobre el citado deber jurídico, abordando los principales problemas bioéticos involucrando la vacunación, destacando los eventos adversos post-vacunación. Concluimos que la Bioética no se propone a establecer normas coercitivas, sino que contribuye a la solución de los conflictos morales identificados en cada caso concreto al ofrecer parámetros. El derecho brasileño busca asegurar el derecho a la salud en su dimensión colectiva al establecer la obligatoriedad de la inmunización para los niños

The objective of this article is to analyze the legal and bioethical aspects of mandatory vaccination of Brazilian children. First, we present vaccination as a duty arising from fundamental right to health of children. Afterwards, it makes a bioethical discussion about the legal duty of children's vaccination, addressing the main bioethical problems involving vaccination, especially the postvaccination adverse events. We conclude that Bioethics does not propose to establish coercive norms, but that it contributes to the solution of the moral conflicts identified in each concrete case by offering parameters. Brazilian law seeks to ensure the right to health in its collective dimension when establishing the mandatory immunization for children

L'objectiu d'aquest article és analitzar els aspectes jurídics i bioètics de la vacunació de nens brasilers. En primer lloc, presentem la vacunació com un deure derivat del dret fonamental a la salut dels nens. Després, es realitza una discussió bioètica sobre el citat deure jurídic, abordant els principals problemes bioètics involucrant la vacunació, destacant els esdeveniments adversos post-vacunació. Concloem que la Bioètica no es proposa a establir normes coercitives, sinó que contribueix a la solució dels conflictes morals identificats en cada cas concret en oferir paràmetres. El dret brasiler busca assegurar el dret a la salut en la seva dimensió col·lectiva en establir l'obligatorietat de la immunització per als nens

Ethics in Child and Adolescent Psychiatry Training: What and How Are We Teaching?

OBJECTIVE: This article describes survey results describing ethics/professionalism curricula of US child and adolescent psychiatry (CAP) residency programs. This project repeated and expanded upon an earlier survey. METHODS: CAP program directors were sent an e-mail with a link to an anonymous electronic survey. RESULTS: Ninety-nine programs responded with 92 completing the majority of the survey. All had instruction during both training years; reading seminars and lectures were the most common teaching formats. The median number of teaching hours was 10. Teaching was considered inadequate by 22%. Confidentiality, child advocacy, and informed consent were the most frequent ethics topics. Communication, patient care during working hours, and conduct at work were the most common professionalism topics. Faculty and resident opinion differed on certain topics. CAPs were preferred educators in 56.5%. External program resources were available to 87% but over 30% used them rarely or never. Faculty evaluations, 360-degree evaluations, and faculty observations were the most common assessment methods; 38% thought trainee assessments need improvement. Programs were classified into more confident and less confident. More confident programs used available ethics resources more frequently (25% vs 8%, p = 0.30) and had more than the median teaching hours (58% vs 35%, p = 0.035). CONCLUSIONS: Compared to the previous study, CAP programs had increased use of interactive methods with more programs reporting having adequate hours. These results are consistent with existing literature confirming the importance of this curriculum but significant issues with adequately educating and evaluating trainees remain.

Intersexual Births: The Epistemology of Sex and Ethics of Sex Assignment.

This article aims to analyse a possible manner of approaching the birth of intersexual children. We start out by summing up what intersexuality is and how it is faced in the dominant clinical practice (the "treatment paradigm"). We then argue against this paradigm, in favour of a postponement of genital surgery. In the second part of this paper, we take into consideration the general question of whether only two existing sexes are to be recognized, arguing in favour of an expansion of sex categories. In the third part, we illustrate the reasons supporting provisional sex attribution: the child's best interest and respect for their developing moral autonomy. This position aims to increase the child's well-being and self-determination, limiting parents' freedom to take decisions on behalf of others, in particular, those decisions concerning basic aspects of their children's personal identity.

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children.

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill's "harm principle" should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill's harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.

When Parents Refuse: Resolving Entrenched Disagreements Between Parents and Clinicians in Situations of Uncertainty and Complexity.

When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a "think list" of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.

The principle of the best interests versus the wellbeing of the child in biomedical research / El principio de los mejores intereses versus el bienestar del niño en la investigación biomédica

The singularity of biomedical research on children requires specific criteria that cater to the delicate interests in play. Quality research can be regarded as a fundamental right and is also an indispensable tool for human, medical and scientific progress. Research on children is also necessary and advisable in order to be able to attend to their specific needs, but it requires additional guarantees which should be applied to the assessment of research. This paper analyzes the main issues related to the binding principle of best interests of the child in the field of biomedical research, and contends that it can be useful for biomedical research decisions on children, though not in its absolute interpretation which holds that the best interests of the child should prevail over any other, but rather in an interpretation geared more towards the child's wellbeing (Kindeswohl), seeking the conscientious protection of under-age children. Only such an interpretation could permit research which does not benefit the child, provided that the burden and risk were minimal. According to this, the author proposes the term "wellbeing of the child" to replace the concept of the best interests of the child in the pertinent legislation

La singularidad de la investigación biomédica en niños requiere criterios específicos que se ajusten a los delicados intereses en juego. La investigación de calidad puede considerarse como un derecho fundamental y también una herramienta indispensable para el progreso humano, médico y científico. La investigación en niños es también necesaria y aconsejable para poder atender sus peculiaridades específicas, pero requiere garantías adicionales que deben aplicarse a la evaluación de la investigación. Este artículo analiza las principales cuestiones relativas al principio del interés superior del menor, de carácter vinculante, en la investigación biomédica. Se destaca la utilidad del principio en este campo, aunque no en su interpretación absoluta que hace prevalecer dicho interés sobre cualquier otro, sino en una interpretación más orientada a su bienestar (Kindeswohl), buscando la protección concienzuda de los menores de edad. Solo una interpretación de este tipo podría permitir una investigación que no beneficie al menor, siempre que la carga y el riesgo sean mínimos. De acuerdo con esto, la autora propone el término "bienestar del niño" para reemplazar el concepto del interés superior del menor en la legislación pertinente

A threshold of significant harm (f)or a viable alternative therapeutic option?

This article critically examines the legal arguments presented on behalf of Charlie Gard's parents, Connie Yates and Chris Gard, based on a threshold test of significant harm for intervention into the decisions made jointly by holders of parental responsibility. It argues that the legal basis of the argument, from the case of Ashya King, was tenuous. It sought to introduce different categories of cases concerning children's medical treatment when, despite the inevitable factual distinctions between individual cases, the duty of the judge in all cases to determine the best interests of the child is firmly established by the case law. It argues that the focus should not have been on a threshold for intervention but on whether his parents had established that the therapy they wanted was a viable alternative therapeutic option. In the April hearing, Charlie's parents relied on the offer of treatment from a US doctor; by July they had an independent panel of international experts supporting their case although by this time the medical evidence was that it was too late for Charlie. One of Charlie's legacies for future disputes may be that his case highlighted the need for evidence as to whether the treatment parents want for their child is a viable alternative therapeutic option before a court can determine which therapeutic option is in the best interests of the child.

Negotiating Ethical Paradoxes in Conducting a Randomized Controlled Trial: Aligning Intervention Science with Participatory Values.

In this article, we describe ethical tensions we have faced in the context of our work as intervention scientists, where we aim to promote social justice and change systems that impact girls involved in the juvenile legal system. These ethical tensions are, at their core, about resisting collusion with systems of control while simultaneously collaborating with them. Over the course of designing and implementing a randomized controlled trial (RCT) of an ecological advocacy intervention for girls, called ROSES, ethical paradoxes crystalized and prompted us to engage in critical reflection and action toward the aim of moving away from conducting research on legal-system-involved girls and moving toward a more democratic, participatory process of inquiry with girls. Our experience revealed two intertwined paradoxes that ultimately served generative purposes. First, in collaborating with legal system stakeholders, we observed a single story of girls' pathology narrated for girls, without girls, and ultimately internalized by girls. Second, in reflecting critically on the ethical implications of our study design, it became clear that the design was grounded in a medical model of inquiry although the intervention we sought to evaluate was based, in part, on resistance to the medical model. We describe emergent ethical tensions and the solutions we sought, which center on creating counternarratives and counterspaces that leverage, extend, and disrupt our existing RCT. We detail these solutions, focusing on how we restructured our research team to enhance structural competence, shifted the subject of inquiry to include the systems in which youth are embedded, and created new opportunities for former research participants to become co-researchers through formal roles on an advisory board.

"But We Want to Work": The Movement of Child Workers in Peru and the Actions for Reducing Child Labor.

The program Edúcame Primero (Educate Me First) is an evidence-based practice for eradicating child labor that has been applied with positive results in Colombia, Peru, and several Central American countries. In this article, we describe the difficulties of implementing the program in two poor areas of Lima (Peru) between 2014 and 2016. Specifically, we discuss three ethical challenges faced during the implementation of the program: (a) the existence of a movement of working children that defends the right of children to work; (b) the polarization of some community-based associations and government institutions on how to deal with the problems of working children; and (c) the use of network indicators in the evaluation of the community's level of cohesion. Taking the Code of Ethics of the General Council of Associations of Psychologists in Spain as a guide, we adopted a consensus approach in planning and research design, combining different criteria of value with the participation of different stakeholders. The implementation of the program in Peru gave preference to developing skills in children over changing attitudes in relation to child protection, although the intervention openly declared its aims when engaging institutions and families. Finally, we address how social network research places special ethical demands on conventional ethical standards. Our experience with this project shows the importance of acting as a bridge between different stakeholders and assessing how all of them benefit from the intervention.

Manipulación del lenguaje, maternidad subrogada y altruismo / Language Manipulation, surrogacy, altruism

La neolengua propicia un cambio del sentido de las palabras y junto al doble pensamiento forma el cuadro del totalitarismo descrito por Orwell en 1984. El propósito de la neolengua es hacer imposible toda otra forma de pensamiento. En la bioética la neolengua se aplica, no porque sea una ciencia nueva sino por la intención manipuladora. El lenguaje político del siglo XX tiene, según Orwell, la intención de alejar la "imagen mental" de lo que realmente acontece. Esto es claro en los términos "maternidad subrogada". Por un lado se priva a la madre de su hijo. Por otro no hay subrogación en sentido jurídico. Como se ha dicho la técnica reduce a una mujer a la condición de un recipiente. La coartada del altruismo no modifica la relación explotadora, pues la gratuidad en la prestación de la mujer no es altruismo de todos los que intervienen en la subrogación

The Newspeak propitiates a change of the sense of the words and next to the double thinking forms the picture of totalitarianism described by Orwell in 1984. The purpose of the Newspeak is to make all other forms of thought impossible. In bioethics the Newspeak is applied, not because Bioethics is a new science but by the manipulative intention. The twentieth-century political language has, according to Orwell, the intention to remove the «mental image» of what really happens. This is clear in the terms"surrogacy" On the one hand, the mother is deprived of her child. On the other, there is no legal subrogation. As has been said the technique reduces a woman to the condition of a vessel. The excuse of gratuity does not change the exploitative relationship, since gratuitousness in the provision of women is not the altruism of all those involved in surrogacy