If your hospital system is like mine, it has a dedicated pediatric emergency department. A place connected to a larger children’s hospital, where all of the providers, including nurses are certified in pediatrics. They also offer a whole host of other pediatric support, like child life specialists, without whom I would not be able to suture a laceration or obtain cerebrospinal fluids samples. All of the people have one goal, the safety and well-being of the child.  This system, as you might expect, fosters a unique culture of medicine; a culture which I assert is heavily steeped in paternalism.

My patient is 17, has a medical history significant for PTSD and depression with one prior hospitalization for suicidal ideation in the setting of substance abuse. She ran away from her home overnight and was indulging in substance abuse and protected consensual sex with her boyfriend of the same age.  Her mother brought her in and wants her admitted to the hospital.  The patient does not want to be admitted. She is calm, rational, and seems pretty reasonable with good insight into her situation. She says “My mom worries about me, but all I’m doing is smoking weed because I can’t deal with her [expletive].” She has no complaints, is not doing any other drugs, has had suicidal thoughts in the past, but none today, and no delusions or homicidal ideation. Contrarily, her mother declares that “my daughter is out of control” and she threatens her when they get into arguments. She doesn’t “feel safe with [her daughter] at home.” She is falling back “in with the wrong people.” One of these days she is going to get the phone call that [my daughter] is dead, and it will be “[my] fault” for letting let her go home.

Ooof, that stings. Most ER providers I have met knew this case was a doozy from reading AWOL as a chief compliant. If you are like me, you possibly even delayed going into the room because you knew it was going to be rough emotionally. My question is “Now what?”

In my patient’s case, she was eventually admitted to the hospital to await placement at our local psychiatric and rehab center. Right or wrong, it is what happened to her. This decision was reached at the end of an iron decision-chain forged in the fires of the paternalistic culture that surrounded it.

“Who knew there were so many types? For instance, it came to my attention that I routinely practice passive paternalism when I neglect to tell a child that they need stitches until the last moment to spare them the pain of anticipation.

Taken from Miller RB. Children, Ethics, and Modern Medicine

Paternalism is not inherently bad. Most pediatric providers will tell you that they treat the patient and the whole family too.[4,5] The actions they take, or do not take, are weighed with consideration of duty to treat, perceived benefit, likelihood of harm, parent’s wishes, and what the child themselves might want. This makes sense. No 5 year-old I’ve ever met wanted to get IV fluids. Informed consent requires understanding of the risks and benefits. As a child’s brain develops they become able to understand their treatments and their piece gets bigger in the ethical calculus until magically at age 18, it is theirs to own. Paternalism on a sliding scale.[3,6] This is particularly tricky in patients like mine, who, in less than a year, can do medico-legally do whatever they want.

What did we treat in the hospital? Substance abuse I suppose, to a minimal benefit. However, when we admitted her against her wishes we harmed her perceptions of medical care, perhaps forever, and temporarily used a finite resource. The benefits of coercing care in this patient are minimal as she is unlikely to “buy in” to therapy (a pre-requisite in all adult medicine). The mother, obviously, wanted her admitted and essentially said that she wouldn’t “take her home.”

So why did we admit her? Did we value the mother’s desires over our patient? Were we wrong to try and place her? Was it ethical to essentially force hospitalization on someone who wouldn’t even have to sign against medical advice forms to leave the hospital next year? Will she thank us in eight years once her brain is “fully developed?”[1]

I argue that we admitted her because of paternalism. We saw her as a lost young woman, a lost “girl.” Someone for whom, “we just wanted the best” and who couldn’t be trusted to make a rational choice. Yes, the best time to intervene is early, and yes, in some ways she was making bad choices. But we should not shy away from the fact that we minimized her agency. We should acknowledge that our decision was directly based on paternalistic ideas about her. I believe that we allowed our perception of her to cloud our judgement and we should also categorize the environment which allows such decisions to be made.

Emergency care on its own is inherently coercive.[2,5] This has been discussed robustly for adults and children alike; in general paternalism plays a larger role in the emergency department than in primary care or other more elective branches of medicine.

The pediatric ED is doubly-governed by paternalism as it involves both children and emergencies, two areas where its application is supported.[2] Many of our decisions occur in rapid fashion with lifesaving intent, making ethical concerns vanish under threat to life or limb. Can’t reach the parents for consent, intubate anyway. Yelling cinematically like Mr. Clooney or Dr. McSteamy “NO TIME, THEY NEED BLOOD STAT!” We exercise a much greater degree of freedom with our paternalism granted to us by the law and the expanded understanding that both children and parents will thank us when they are alive later.

What about our patient? There was absolutely nothing emergent about her presentation. Her life was no more in jeopardy  than anyone would be driving a car or playing a contact sport. At some point, her choice needs to matter. Is there a magic age in which her agency should be sacrosanct?  I do not know the answer. But, I do know that paternalism rears its ugly head in many ways in the pediatric emergency department, and much of which I have felt for myself.

Figure 2 is a Completely Accurate Graph from a Fictional Data Set where the x-axis is average times/day I am referred to by the above terms in a given month. Interestingly in month 2 I visited my family in the south which led to a second peak of Sweeties, and in the 4th month I went on vacation reducing my title being voiced at all.

For example, if the number of times I was called sweetie, hun, or doctor was on the y axis, were plotted over time, you would see a massive spike in sweeties and huns over my pedi-ED months. I also noted a spike in the number of times my order for critical medications were delayed in administration because the nurse wanted to quiz me about my indications, risks and benefits. Is this because I am a new doctor, because I have limited experience with pediatric patients, or is it because the staff is “over-protective” of their patients? I’m not sure, maybe all of the above. I only mention it because it seems paternalistic, based on my experiences which are firmly rooted in my intersectionality.

It does not, however, take into account my race, gender or age. As an >35-year-old white male, I already look like the media’s perceived notion of what a doctor “should” look like. I know that I am being greatly shielded from the paternalistic views of the staff, nurses and attending physicians.  A female adult EM colleague 10 years my junior, with the same training tells me that she doesn’t even get asked to verify a medication; nursing will go over her head to the attending or just not give it. Presumably this difference is accounted for by the difference in perception. Again, paternalistically another “girl” has not yet “earned her seat at the table,” and shouldn’t be trusted to make that choice.

I argue that paternalism as a culture trains us to see people using our preconceived notion of who they are, rather than as they are. As such, our own biases play an outsized role in decision-making because they are hidden from our (supposedly well-developed) frontal lobes. For example in both my patient’s and my colleague’s stories the idea of the person leads to limiting of their agency.

I am not saying paternalism on its own is wrong. I have many thoughts about end of life care, decision making in emergencies, etc. which I would argue necessitate a paternalistic approach. I am saying that we should enhance our awareness of the reaches of paternalism’s effects into our unconscious minds. We cannot allow “it” to make decisions for us. As providers, it is critical for us to recognize paternalism when it is happening to avoid its influence, and I hope you will now identify it in the pediatric emergency department as I have.

Author: Russell Prichard is a third-year emergency medicine resident at Brown

Faculty Reviewer: Meghan Beucher is an Assistant Professor in pediatric emergency medicine at Brown 

REFERENCES

1.     Durston, S., Hilleke, E., Hulshoff, P., Casey, B. J., Giedd, J. N., Buttlelaar, J. K., & VanEngeland, H. (2001). Anatomical MRI of the developing human brain: What have we learned? Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1012–1020.

2.     Clarke, J., Sorenson, J., & Hare, J. (1980). Ethical Problems in Clinical Practice: The Limits of Paternalism in Emergency Care. The Hastings Center Report, 10(6), 20-22. doi:10.2307/3560292

3.     Miller RB. Children, Ethics, and Modern Medicine. Bloomington, IN: Indiana University Press; 2003. http://search.ebscohost.com.revproxy.brown.edu/login.aspx?direct=true&db=e000xna&AN=138424&site=ehost-live&scope=site. Accessed April 1, 2020.

4.     Moisa SM, Gramma R, Parvu A, et al. Models of decision making in pediatrics - part I. Romanian Journal of Pediatrics. 2013;62(1):39-42. http://search.ebscohost.com.revproxy.brown.edu/login.aspx?direct=true&db=aph&AN=88796307&site=ehost-live&scope=site. Accessed April 7, 2020.

5.     Moisa SM, Gramma R, Parvu A, et al. Models of decision making in pediatrics -- part II. Romanian Journal of Pediatrics. 2013;62(2):123-127. http://search.ebscohost.com.revproxy.brown.edu/login.aspx?direct=true&db=aph&AN=89040746&site=ehost-live&scope=site. Accessed April 7, 2020.

6.     Paul TK, Vercler CJ, Laventhal N. A Dose of Paternalism: How Eliciting Values, Not Amplifying Parental Permission, Can Promote the Interest of Children and Families. American Journal of Bioethics. 2017;17(11):24-26. doi:10.1080/15265161.2017.1378767.