1. Background
Medical education is a program that goes far beyond the mere transfer of knowledge and diagnostic/ therapeutic skills; encompassing behavioral culture, business values, beliefs, and identities of the medical career (1). In other words, medical education includes moral teaching programs with the aim of creating clinical decision-making skills and institutionalizing professional ethics for physicians (2). As a matter of fact, professionalism provides physicians with hints on the Do’s and Don’ts of ethics, and educates them on the codes of practice on how to deal with both patients and colleagues (3). Since medical students face many ethically-related issues in their career (4), the development and consolidation of ethics are considered as the most important educational goals at different levels of education in medicine (5).
Effective teaching of medical ethics to medical students should be based on their educational needs. From the perspective of Indian medical students, issues raised in medical ethics need to be applicable to the actual practice of pediatrics (6). According to the results of a research project conducted in Iran on the quality of medical ethics curriculum from the perspective of Iranian students, the curriculum had an unfavorable condition (2). However, an assessment of medical students’ views in Saudi Arabia revealed their satisfaction with the medical ethics curriculum; yet, they still believed that the curriculum needs to be shifted to a patient-centered one (4).
In the field of pediatrics, new ethical challenges have emerged along with new developments. Some of the biggest ethical challenges in pediatrics are issues related to moral decision-making (7). Thus, in the field of pediatrics, do-not-resuscitate (DNR) order is amongst the most serious ethical challenges for residents (8, 9).
In addition, residents of pediatrics with multiple roles in their career as educators, students and clinicians, studentship, and clinician face particular moral challenges (10). Residents often encounter additional challenges compared to the other disciplines because of having to deal with patients, who are receiving healthcare services as well as their families (11).
A recent study on this issue showed that the most challenging problems in neonatal care in Iran were related to patients’ rights, interactions with parents, communication and cooperation, and end of life concerns (12). The findings of other studies conducted in Iran have indicated that in cases where patients experience terminal illness, dilemma in choosing whether to prolong treatment or allow the normal process of dying to take place is a key challenge for physicians yet is not considered futile (13, 14). According to the results of another study in Iran, despite the positive attitude of doctors towards DNR orders, absence of a clear legal guidance regarding this issue leads to various problems in physician’s decision-making and necessitates clear instructions/rules from governing bodies in the country (15). Notably, diseases, as one of the factors giving rise to major changes in the lives of people, affect both the patients and their families (16). On the other hand, a study conducted in Iran demonstrated that major clinical challenges, from the view point of medical students, were rooted in not respecting the patient’s autonomy (1). Clinically-related ethical issues are not included in current training programs for pediatrics residents (10).
Based on the available literature, no studies were found on the viewpoints of Iranian residents in ethical challenges in the field of pediatrics. Therefore, this study was conducted with the aim of identifying ethical challenges in the field of pediatrics from the perspective of pediatric residents.
2. Methods
This research was a cross-sectional study. The research population included all pediatric residents studying at 3 major teaching hospitals (Bahrami and Imam hospitals, and children’s Medical center, which are coded as A, B, and C for confidentiality purposes) affiliated to Tehran University of Medical Sciences (TUMS). This study was conducted over the last 9 months, in 2015. The 3 centers are listed alphabetically in Table 1. The sample size was calculated using the census method (also called the complete enumeration survey method).
Table 1.The Residents’ Demographic Profile
| Demographic Data | Number | Percentage, % |
|---|---|---|
| Age, y | ||
| 25 - 35 | 58 | 64.4 |
| Older than 35 | 32 | 35.6 |
| Marital status | ||
| Married | 68 | 75.5 |
| Single | 22 | 24.5 |
| Year of residency | ||
| First (internship) | 29 | 32.6 |
| Second year (junior) | 30 | 33.7 |
| Third year (senior) | 31 | 34.4 |
| Hospitala | ||
| A | 17 | 22.4 |
| B | 41 | 53.9 |
| C | 18 | 23.7 |
| Education record of attendance in medical ethics courses | ||
| Qualified | 72 | 80 |
| Unqualified | 18 | 20 |
aDue to confidentiality, the teaching hospitals are shown as A, B, and C.
The tools used in this study included demographic variable forms and a questionnaire to evaluate residents’ opinions towards ethical challenges in the field of pediatrics. Demographic variables included age, gender, marital status, years of residency, teaching hospital, and attendance of educational programs on medical ethics. The instrument for measuring inhibiting factors was designed by the research group, based on relevant literature on the subject and the comments made by 10 faculty members and experts in the field of medical ethics and pediatrics. For this purpose, the items were reviewed and revised using the viewpoints of this expert group during 3 sessions, so that a few questions with similar contents, or obscure or unnecessary items were deleted or modified. Finally, following these revisions, the questions received the final approval of the panel of experts. The final questionnaire consisted of 32 items with a 5-point Likert scale with ordered response options of strongly agree, agree, neither agree nor disagree, disagree and strongly disagree”, with a score of 1 to 5 assigned to each item, respectively. Thus, the score range of this instrument was between 32 and 160. The items in the assessment of ethical challenges included proper decision making in dealing with colleague misconduct and appropriate professional behavior in the relationship between doctors and other health care team members.
Validity and reliability of the above instrument were assessed by the authors, using content validity and test-retest methods. To obtain content validity, the opinions of 10 faculty members of TUMS, expert in the field of pediatrics and medical ethics, was considered. In addition, to obtain the reliability of the instrument, using the test re-test method, the instrument was left at the disposal of 10 pediatric residents from another university, and the results of the two tests were evaluated using Pearson’s correlation coefficient of 0.92.
Data analysis was done using descriptive statistics (Mean and Standard deviation) and inferential statistics (linear regression) with the SPSS version 16 software. The significance level was considered at 0.05.
This study was approved by the ethics committee of TUMS in coordination with the educational deputies of these medical centers. Informed consent was obtained from the participating residents after providing necessary information on the study as well as confidentiality of the collected data.
3. Results
Most participants in this study were female (n = 72, 80%). Other information on relevant demographic characteristics of the studied population is presented in Table 1. According to the findings, providing enough information on obtaining informed consent (4.74 ± 0.22), dealing effectively with the decisional conflicts between sick children and their families (4.68 ± 0.14), giving bad news to an ill child or their parent (4.64 ± 0.18) and taking appropriate actions in dealing with cases of child abuse (4.62 ± 0.16) were the most serious ethical challenges in the field of pediatrics from the perspective of pediatric residents. Mean and standard deviation of other factors are specified in Table 2. In addition, based on linear regression analysis, there was a significant correlation (P = 0.03, r = 0.059) between the resident’s gender and their views towards the ethical challenges; female residents paid more attention to these challenges compared to male residents. No significant relationship was observed with other demographic characteristics. Linear regression results are shown in Table 3.
Table 2.Mean and Standard Deviation of Each Item of the Instrument
| Items | Mean ± SD |
|---|---|
| Suitably dealing with family misconduct with child | 4.57 ±0.32 |
| Maintaining confidentiality of child and parents | 4.52 ± 0.25 |
| There is a written process to cut child maintenance therapy patients at the end of life | 4.49 ± 0.30 |
| Availability of a written procedure (Guidelines) for DNR orders | 4.44 ± 0.28 |
| Appropriate professional behavior in the relationship between doctors and other health care team members | 4.37 ± 0.44 |
| Respecting child’s rights as a research subject | 4.33 ± 0.26 |
| Respecting child’s rights as an educational subject | 4.31 ± 0.21 |
| Due decision-making on colleague misconduct | 4.28 ±0.52 |
| Lack of conflict of hospital rules and regulations with professional ethics principles | 4.18 ± 0.42 |
| Dealing with sick children and families at the time of futile treatment | 4.17 ± 0.64 |
| Respecting sick child and family dignity and decency | 4.16 ± 0.74 |
| Sick children and their families access to an efficient system for handling complaints | 4.15 ± 0.36 |
| Respecting patient’s privacy | 4.08 ± 0.59 |
| Optimal pain control of child’s pain | 4.02 ± 0.44 |
| Maintaining the right for mother or father to stay with sick child | 3.98 ± 0.87 |
| Providing minimum conveniences for continued presence of mother with her child | 3.96 ± 0.92 |
| Respect cultural and religious beliefs of sick children and family | 3.88 ± 1.06 |
| Availability of a written procedure for selecting from among sick children for the allocation of limited resources | 3.82 ± 0.91 |
| Avoiding limitations for sick child | 3.81 ± 0.86 |
| Monitoring the safety of implementing aggressive measures for sick children | 3.77 ± 0.48 |
| Non-discrimination between sick children in the provision of services | 3.74 ± 1.1 |
| Proper management of one’s medical error and those of colleagues | 3.7 ± 0.46 |
| Integration of caring for sick child between different hospital units and wards | 3.67 ± 1.04 |
| Non-interference in unqualified areas | 3.63 ± 0.66 |
| Referrals or unnecessary actions to obtain personal and financial gains to be avoided | 3.47 ± 1.15 |
| Non-denial of treatment sick child or their legal guardian | 3.26 ± 0.79 |
| Appropriate attire and appearance of medical staff | 3.05 ± 0.76 |
| Euthanasia | 2.88 ± 0.68 |
Abbreviation: DNR, Do Not Resuscitate.
Table 3.Linear Regression of Test Results
| Demographic Variables | Importance of Ethical Challenges | |
|---|---|---|
| P Value | R | |
| Age | 0.83 | 0.049 |
| Gendera | 0.03 | 0.059 |
| Marital status | 0.72 | 0.067 |
| Year of residency | 0.74 | 0.046 |
| Hospital | 0.63 | 0.045 |
| Record of attendance in medical ethics courses | 0.66 | 0.036 |
aSignificant relationship.
4. Discussion
The residents of pediatrics faced numerous ethical disease-related challenges pertaining to the patients’ families in addition to those relating to the patients themselves, which culminates to create a variety of existing ethical challenges for them.
In this study, by analyzing the opinions of participating residents regarding ethical challenges in pediatrics, it was revealed that providing adequate training for obtaining informed consent, dealing effectively with conflicts between sick children and their families, taking appropriate actions in dealing with cases of child abuse, and proper process of giving bad news to an ill child or his/her parents were the most distinct ethical challenges in pediatrics.
Results of a study in Iran showed that the most significant ethical challenges expressed by medical students were issues related to obtaining informed consent, which were in concordance with the current findings (1). These findings stated that Iranian professionals had general ideas regarding the importance of informed consent, yet were not educated in depth regarding its specific importance, content application, and practice (17). The results of one study demonstrated that Iranian physicians need to be educated more in respecting patients’ rights, including patients’ access to information and their ability of making appropriate decisions (18).
In addition, according to the results of a study from England, the most important ethical challenge in pediatrics was related to patients’ decision-making processes (19). From the medical ethics viewpoint, it is important to note that children do not enjoy legal capacity to give informed consent and take due decision for treatment, which creates additional fiduciary responsibilities (20).
Patients younger than 18 years of age need a parent or a legal guardian to sign the consent form on behalf of them in the country. In some cases, surrogate’s improper decision making (proxy decision making) is the issue that makes proper ethical approaches towards sick children more challenging. Parental authority to decide about their child’s treatment leads to even more challenges in ethical terms as the appropriateness of parents’ decision in this regard is not always clear (21). Currently, there are no official plans designed for Iranian families on proper decision making for pediatrics. There are specific shortcomings in instances of life-threatening child diseases. In some cases, parents experience doubt in decision making.
A well-organized communication in delivering bad news to a sick child and his/her family was another factor of importance among the mentioned ethical challenges in this study. The way to be forthright with parents and ill children, particularly when a certain disease turns out to be life-threatening or the child has not developed to an optimum level of perception, is among the most challenging issues in medical ethics in general, and in pediatrics in particular. The attitude of healthcare staff in telling the parents or the child about the diagnosis in an honest and truthful manner is the key to the treatment of sick children and their families’ decision-making processes (22).
Another ethical challenge reported in this study was to properly give bad news to the sick child and their family. According to the findings of a study in Iran, physicians have a key role in conveying bad news to patients and their families and should therefore be educated in practical skills to be able to give bad news in a correct way (23). Giving bad news is an essential part of pediatrics care. As a result, expression of truth is necessary to avoid worsening the dilemmas and ethical challenges.
Other findings revealed that appropriate action in dealing with cases of child abuse and the misconduct of the family with the children was marked as other factors of ethical challenges in the field of pediatrics. From a moral point of view, one correct approach in this regard is to support and provide care for the abused child and their families (24). Also, because child abuse could lead to moral corruption in the abused child in the future, another appropriate measure in this field is to prevent harassment to children in order to relieve their physical and mental distress and help improve their health in the long-term (25).
Unfortunately, the phenomenon of child abuse is considered as a minor problem in many of developing countries because these communities face a lot of economic and social crises, overshadowing the importance of addressing this issue. However, paying attention to the phenomenon of child abuse is important for the healthcare system (26). Since the pediatrician is the first healthcare staff confronting abused children, it is necessary to consider child abuse with an ethics-driven approach by the children’s physician.
In the present study, maintaining the confidentiality of the child or parents was reported to be another challenging issue. In the field of pediatrics, concerns about patients’ confidentiality leads to greater respect for the child and his/her family.
According to ethical codes, maintaining the confidentiality of patient’s information by a physician is necessary. However, it should be noted that medical confidentiality is not an absolute rule, and the doctor has the authority to take a decision, based on rational and religious grounds, and in the best interest of the patient, imposing the least harm to the patient and his/her family (27).
By investigating the residents’ views, it was revealed that the availability of a legally written process to withdraw life-sustaining treatments at the end of life period and DNR was another challenging issue in pediatrics. In this regard, Dutch researchers demonstrated that doctors faced various challenges if life-sustaining treatment for children was concerned (28). Unfortunately, in Iran, there exists no approved clinical and ethical guidelines to determine when and how DNR orders are assigned, and in some cases, this is discussed informally without the knowledge of the patient or his/her family. These uncertainties about DNR has caused much controversy and confusion among healthcare staff about what they should do when managing a clinical situation (29). As a matter of fact, making comments on continuing patient’s treatment during the end-of-life period is a fundamental skill required by physicians and gives rise to scientific, ethical, and legal challenges.
Furthermore, according to the results, appropriate professional behavior in the relationships between physicians and other members of the healthcare team is another ethical challenge in pediatrics. One of the main concerns in the healthcare system is to respect values and ethical principles across inter-professional co-operations. To this end, a framework has been designed in Iran, which emphasizes on doctors’ adherence to the principles of professional ethics, paying attention to individual and social values, and managing ethical challenges in relation to a variety of professional issues (3). Additionally, since one of the ways to extend ethics across organizations is to define ethically-accepted behaviors in the form of moral codes, there has been relevant codes legislated in Iran; correct communication with colleagues is among the topics considered in this respect (30).
Considering children’s rights as research and educational subjects in the field of pediatrics, prevention of ethical challenges in this regard was another finding of the present research; findings of other studies have also confirmed this issue (31, 32).
In this study, the most important ethical challenges in pediatrics were analyzed from the viewpoints of the residents in this discipline. With a comprehensive look at these factors, it is possible to provide adequate health care services for children and deal with the existing ethical challenges properly. Clear guidelines, educational opportunities, and priority safety issues in the care provided to children are crucial points in the field of pediatrics and for health care providers in order to increase children’s safety and decrease their moral distress (33, 34).
In this study, euthanasia was among the less important ethical challenges from the residents’ point of view. This result was the same as a previous study, which was performed among Iranian nurses with negative attitudes regarding euthanasia (35). Although in the field of pediatrics, euthanasia has been accepted in some countries, such as the Netherlands and Belgium and is being applied in clinical settings (36), this issue has not been accepted by the Iranian law or the health care system (37). Additionally, euthanasia is not acceptable according to the Iranian culture and religion. This is why euthanasia was not considered as an important challenging issue from the pediatric residents’ points of view.
In general, instead of practicing a discriminatory approach, different aspects of ethical challenges in pediatrics should be studied and examined comprehensively with the help of experts in related fields, and appropriate solutions must be determined by anticipating different situations.
In accordance with other findings, there was a significant correlation between the residents’ gender and their views on the importance of ethical challenges, while this relationship was not observed across any one of the demographic characteristics; female residents, as compared to male residents had focused more on challenging ethical issues. This could be explained by psychological differences between males and females. Accordingly, females are more sensitive than males and this factor has a great impact on their understanding of ethical challenges.
This study also had some limitations. Investigating the importance of ethical challenges only from the pediatric residents’ points of view limited the use of findings in this study; and as a result the findings cannot be generalized to ethical challenges in other fields of medicine. Additionally, the views of pediatric residents were evaluated only in one medical university in Tehran, and could be considered as another limitation. Therefore, it is recommended to investigate the attitudes of other medical specialties about the importance of ethical challenges in order to achieve more reliable results in this regard.
4.1. Conclusion
Although occurrence of various challenges, particularly ethical challenges, in clinical settings is inevitable, based on the results of the current study, identifying the most important ethical challenges in pediatrics, from the viewpoint of residents in this field, warns the healthcare system officials to take action to develop a favorable context in clinical settings in a way that pediatrics would encounter minimal ethical challenges. On the other hand, educational programs and availability of clear guidelines are crucial in the field of pediatrics to decrease challenges. From the perspective of residents of pediatrics, by identifying the importance of ethical challenges in the field of pediatrics, the quality of health care services for children were improved by the residents through timely interventions, while reducing ethical challenges.
