Ethical Issues in Treating Pediatric Rehabilitation Patients Ethical issues pertaining to treating pediatric rehabilitation patients stem from at least three sources: the fact that children are not morally autonomous persons and must depend on the values and moral beliefs of others in ethically complex decision-making situations; the extent of parental authority in asserting problematic beliefs or imposing questionable demands affecting treatment decisions; and the way clinical uncertainty affects moral uncertainty in determining treatment approaches or alternatives. Although these problems are pervasive among all age groups of children with disabilities, this article will primarily examine their impact on the rehabilitation of children and adolescents. Principles and strategies for managing value-laden conflicts will be discussed along with how various ethical, social, and clinical constraints may nevertheless compromise a straightforward resolution of an ethically vexing situation.

John D. Banja, PhD Brigitta B. Jann, MD Department of Rehabilitation Medicine Emory University School of Medicine Atlanta, GA The complexity of bioethical issues pertaining to children with disability occurs not only from the clinical heterogeneity of these patient popUlations but also from the absence of a public philosophy on the rights of and social obligations toward children with serious, chronic illnesses. 1,2 A tremendous degree of bioethical attention and controversy has focused on tragic situations involving infants with catastrophic disabilities whose quality of life elicits grave questions about the ethical appropriateness of aggressive, life-prolonging care. Such controversies extend back at least to Duff and Campbell's 1973 article on withholding life-prolonging treatment from infants with profound congenital anomalies, 3 and became notorious during the Baby Doe cases of the 1980s. 4 The goal of this article, however, will be to explore ethical considerations that arise in not nearly so dramatic scenarios. Also, primary attention will be directed toward the child or adolescent with disability, rather than the neonate. Children, especially those less than 14 years of age, are not legally nor morally autonomous since neither their intellectual ability nor capacity for valuative decision making has crystallized into a reliable mechanism that renders coherent, consistent, and No commercial party having a direct or indirect interest in the subject matter of this article has conferred or will confer a benefit upon the authors or upon any organization with which the authors are associated. NeuroRehabil1993; 3(3):44-52 Copyright © 1993 by Andover Medical.

Ethical Issues in Pediatric Rehabilitation

insightful decisions. 5,6 Because treatment scenarios nevertheless involve at least three sets of interests-the child's, the parent's/guardian's, and the provider's-a variety of valuative conflicts will be explored as they derive from conflicts among beliefs of the various parties in authority. Beginning then with the "morally ambiguous" status of the child with disability, this article will examine moral issues affecting other decision makers (notably parents and providers), how uncertainty inevitably penetrates those decisions, and, yet, how certain ethical principles may be implemented toward ethically appropriate courses of action.

THE BEST INTEREST STANDARD Ethics and law recommend two approaches to situations in which health care consumers are unable to participate in decisions over their care. The first is called "substituted judgment" wherein an attempt is made to determine how an incompetent patient would decide if he or she were able to do so. This approach customarily utilizes a next of kin who has an intimate acquaintance with the patient's decision-making history (i.e., the patient's likes, dislikes, preferences, values, and beliefs) and who could persuasively and credibly relate the patient's decision-making history to the case at hand. 7 The second approach is called the "best interest" standard. When this standard is invoked, the patient's decisional history is not known with sufficient clarity to guide the treatment determination. Consequently, decision making according to the best interest standard necessarily resorts to some person's framework of moral beliefswhether the family's, the health care provider'S, the hospital's, the community's, the state's, etc.-as to what would be the reasonable and humane thing to do for a human being in the patient's situation. Because it is generally agreed that children less than 14 years old have either no coherent or rationally determinate set of beliefs or values or, as in the case ofinf~mts or severely retarded children, are unable to evince anything remotely resembling a belief system, the best interest standard is commonly invoked for them. 5,7

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Over the last decade, however, the best interest standard as applied to children has been attacked in a number of ways. The first source of criticism has targeted seman tical problems inherent in speaking about a very young child's formulating "interests." Other than a primitive desire to be free from pain or discomfort, infants have not developed a psychohistory nor do they have the intellectual capacity whereby they might posit life goals or develop some notion about life's meaning. Because very young children live only in the immediate present, at least one commentator has suggested that they cannot even claim an interest in continued existence because the infant cannot formulate a future-oriented notion upon which the idea of "continued" is predicated. 8 Furthermore, should the child suffer from severe and profound cognitive impairments, he or she may never evolve much beyond this stage and, even later as an adult, will thoroughly depend on how the beliefs and values of others will influence the quality of his or her interaction with the world. Even among intellectually normal children with disabilities, however, decisions about their care will usually be made by others who are neither disabled nor children. If one's "best" interest is to have any substantive meaning, however, it can only be with reference to whomever's interest is being contemplated. Thus, if X is to decide what V's authentic best interests are, X must understand what V's life is like so as to make morally sensible and judicious decisions appropriate to life as Y experiences it. If that empathic understanding is impossible, then the only frame of reference that is available to X will be his or her's, not V's. This leads to the claim that children occupy a "morally ambiguous" status since they are either judgment.ally or politically unable to express their interests in situations which immediately concern them. 9 Obviously, this criticism is pointed within the context of pediatric disablement since children with disabilities are developmentally, psychologically, and functionally different from able-bodied adults. What is ethically at stake in decisions relating to them is the hope that traditional rehabilitation goals associated with functional independence tum out to be in their best interests. As Buchanan and Brock note:

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A child's good is more fully determined by the developmental needs of children generally at that age than by his or her current but predictably transient goals and preferences. These developmental needs are based in significant part on the aim of preparing the child with the opportunities and capacities for judgment and choice necessary for exercising self-determination as an adult. Consequently, efforts to promote children's wellbeing focus prominently on fostering these abilities and opportunities so that as adults they will be able to choose, revise over time, and pursue their own particular plans oflife, or aims and values, now suited to the adults they have become. 5 (pp. 227-228)

Thus, one hopes that whichever determination of the child's "best interests" holds sway does not compromise the fi)rmation of the beliefs, values, and preferences that the child will eventually embrace as an adult. Consequently, pediatric rehabilitation decision making is an inevitably value-laden process since the determination and prioritization (from worst to best) of the child's interests must involve decisions made by persons other than the child. Moreover, the gravity of these valuative decisions become more pronounced when they incur longlasting consequences for the child and his or her caregivers, such as when a decision is made to institutionalize the child permanently rather than care for the child at home. Because it is neither likely nor even warranted that a single individual will unilaterally make all these determinations, the process of determining best interests for children with disability will involve issues over the limits of parental authority and the assuredness of clinical judgment. These issues will be discussed in turn.

THE MORAL STATUS OF THE FAMILY Unless the adult patient is incompetent, health providers are expected to inform and secure consent from that patient before commencing a nonemergency procedure or plan of care. When the patient is a child, however, the moral and legal context of the decision-making process necessarily turns to parents or guardians to make treatment decisions. First and foremost, ethical and legal obligations falling on the health provider in contemplating parental treatment decisions require ensuring

that the child is not seriously abused or imperiled by those decisions. 7 To take a familiar example, although the adult Jehovah's Witness may have the right to refuse blood products for him- or herself, such refusal cannot be made on behalf of his or her child. As the United States Supreme Court ruled in the 1943 case of Prince v. Massachusetts, "Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children." 10 Although the general rule is that parents cannot take steps that would unduly risk their child's being harmed or neglected, the distinction between negligent upbringing versus idiosyncratic child-rearing beliefs and practices is oftentimes not dear. Is a parent's insistence on braces harmful if the child will never walk? What about a similar insistence-over the wishes of the child-to have tendons cut so as to relieve contractures and perhaps simplifY care even though no functional gains will result? The following criteria are suggested by way of acknowledging the considerable authority our society extends to parental decisions, while simultaneously acknowledging that parental authority is not absolute. In contemplating a parental decision that the provider deems questionable, the following questions should be asked: Would the consequences of the parental decision result in serious harm to the child whose gravity is significantly outweighed by any probable benefits? Parents are not expected to display infallible judgment or the patience ofJob. They are, however, expected to execute their responsibilities so as not to inflict harm resulting in the child's becoming dysfunctional or incapacitated. In the case of the child who is already dysfunctional or incapacitated from a disability, this duty might be rephrased so as to ensure that a parent's decision will not seriously aggravate the child's disability. 6 In a 1982 Colorado case, a 12-year-old's mother refused to administer Dilantin for his epilepsy. Despite a petition from the welfare office requesting the court to order treatment, the court supported the mother's refusal (issuing from her belief in faith healing) so long as the child's life was not in imminent danger. When the boy went into

Ethical Issues in Pediatric Rehabilitation

status epilepticus some months later, however, the judge granted the welfare office's petition. The mother appealed, but the Supreme Court of Colorado ruled that '~ child who is treated solely by spiritual means is not, for that reason alone, dependent or neglected, but if there is additional reason, such as when the child is deprived of medical care necessary to prevent a life-endangering condition, the child may be adjudicated dependent and neglected."ll A second question to consider is: Does the parental behavior or decisional preference require the provider to deviate from professional clinical practice? This is an especially important consideration when the parents and child are united against a professional recommendation for treatment. In such situations, providers must have extremely compelling evidence that should rely on (or be derived from) the professional standard of care that the withholding or delay of treatment will result in grievous harm for the child. If the provider cannot make that demonstration, the court is likely to defer to parental authority, especially if the child refuses the treatment and the treatment itself poses risks whose materialization might outweigh whatever benefits would likely materialize. 2 On the other hand, no parent can compel a provider to deliver care that will be nonbeneficial or futile. The chief consideration in these instances is for the provider to be reasonably assured that his or her determination of futility or inefficacy rests on clinically demonstrable grounds. Again, the best gauge of the quality of the professional's opinion will be adverting to the applicable professional standard. If a consensus of professional opinion would urge treatment when the provider resists, however, the clinician's refusal to treat might be interpreted as an abandonment of the patient and invite accusations of negligence. 7 A third question is: Are the parents emotionally and intellectually able to care for their child? The issue here is capacity to parent, wherein the adult must demonstrate at least a minimally acceptable ability to provide the child with physical and emotional support such that the child's maturation can proceed without unnecessary or undue burdens.

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In cases where the provider is reasonably assured of the correct clinical course but parental beliefs or preferences are opposed, providers may face a difficult balancing of two moral phenomena: The first is that the fiduciary duty that qualifies every relationship between a health professional and a client is heightened when the professional's patient is a child. 2 Children do not have and are not expected to have the ability to protect and advocate for their interests as adults do. Hence, when the provider becomes suspicious of the ability of those very persons who are morally and legally entrusted to protect the child's interests, ethics and law expect providers to take reasonable steps to protect the child. Such measures, however, may antagonize the parents, which could have any number of unpredictable but untoward consequences for the child. 13 Chief among these consequences, of course, is the extent to which the parents are willing to cooperate with the professional's therapeutic efforts in the future. Providers, therefore, should be especially sensitive to distinguishing moments where parental decisions can be objectively demonstrated to risk physically or emotionally abusing the child versus those wherein the parent's ideology of child rearing simply differs from the health professional's (and no serious hazard is presented to the child). Parents are accorded remarkable latitude in the United States over determining disciplinary practices toward their children as well as shaping their children's religious beliefs, educations, social interactions, forms of entertainment, personal attire, and receipt of medical treatment. As Holder remarked: The common law rule was and is that treatment of a minor, even without negligence and where the treatment led to a satisfactory result but for which the parents did not consent, gave rise to an action for assault and battery brought by the parents. The child at common law was considered to be virtually a chattel of his or her parents, and thus the parent had an almost absolute right to make decisions affecting the child's welfare. Therefore, any interference with the parent's control of the child, even ifintended as beneficial, gave the parent, not the child, a cause of action against the physician ... Parents do still have a right to sue a physician for administering non-negligent care to a young child without parental consent. 6 (pp. 124-125)

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A parent has no right to handicap a child any more than what has eventuated from a child's life circumstances or disability. Nevertheless, because there is no universally accepted method of child rearing in the United States-perhaps because of a lack of compelling scientific demonstration of the effects of parental influence on the child's well-being coupled with a lack of social agreement on what constitutes "well-being" - health providers need to respect the considerable discretion with which parents can influence the behavior and life of their child.

THE ETHICS OF UNCERTAINTY Health providers who are quick to disagree with parental decisions that are not congruent with their own need to be reminded that day-to-day clinical practice must contend with varying degrees of clinical uncertainty. Uncertainty may arise from a paucity of scientific data, from personal uncertainty over not knowing the patient's wishes, and from conceptual uncertainty about applying abstract criteria to concrete situations. 13 Furthermore, multiple uncertainties may arise and blend with one another in a variety of ways, aggravating the moral complexity of the clinical decision at stake. Because uncertainty inevitably attaches to calculations over the degree of benefit or harm occurring from treatment, it has enormous ethical significance. A morally vexing dimension of decision making among pediatric patients is that many clinical decisions have dramatic, long-term consequences. Because the evolution of medical knowledge is not predictable, today's treatment of choice may be tomorrow's medical embarrassment. Consequently, a certain degree of incalculable, longterm hazard attaches to any procedure that may eventuate in irreversible and unwelcome consequences for the child. A corollary source of uncertainty is whether administering an intervention has any real benefits for the child at one stage in his or her maturation when other interventions could be chosen as well. Uncertainties may plague the provider as to when to stop, begin, or combine various ther-

apies, especially when they involve a mix of physical, cognitive, or behavioral components. An early and intense professional focus on physical functioning, for example, might occur at the cost of concentrating on cognitive training which, in retrospect, might be deemed to have been the better treatment choice. A third and rather serious source of uncertainty for providers is in balancing benefits and burdens attaching to care, where those benefits and burdens are influenced by multiple variables whose impact may ebb and flow over a lifetime. For example, changes in the familial matrix and support services occur with time; quality of life may have a dramatically different meaning at different times; cognition, intellectual functioning, and psychosocial issues have varying prominence over time; and the availability of long-term care provision is unpredictable. Clinical decision making cannot be scientific in these instances in view of the unknowability of future events and how personal values and individual reactions (of the patient, family, or provider) may respond to these vanances. Apart from uncertainties inherent in the unpredictability of the long-term clinical and psychosocial evolution of a pediatric disability, other more immediate sources of clinical uncertainty may prevail. Each of the following types of uncertainty involves difficult decisions over risk-benefit tradeoffs accompanying some treatment:

1. Where the contemplated treatment presents debatable benefit but carries some risk. An example might be surgical treatment of lower-extremity contractures in a child who will never walk. Suppose the contractu res do not interfere with positioning or functioning but are considered to be cosmetically unsightly. Whose aesthetic values should prevail, the child's, the parent's, or the provider's? Will the value of improved appearance eventuate in improved social interactions and less stigma associated with disability or does the risk of surgery outweigh whatever improved cosmesis may result? 2. Where the contemplated treatment promises some functional gain which mayor may not translate into

Ethical Issues in Pediatric Rehabilitation

meaningful or useful function. This issue is especially challenging in cases where the treatment is expensive but the benefits are dubious. An example might be extending ambulation among children with Duchenne's Muscular Dystrophy by as much as a year with long-leg braces. Ambulation in such cases is hardly ever functional and often frightening to the youngster. Yet many parents and sometimes the child will demand every possible intervention to maintain a function they deem critical to their self-esteem. 3. Where the contemplated treatment may hold out real benefits when successful, but is off-set by considerable and hard-to-predict risks. An example might be a rhizotomy or blocks for spasticity. Even though the accuracy of predicting potential outcomes is improving, these interventions still carry significant uncertainty in calculating the possibility of an unfavorable outcome in individual cases. 14,15 4. Where the treatment promi5es functional gains for the patient, but creates profound burdens for caretakers. Parents may press for an early discharge of their child from rehabilitation but not realize the additional care burdens entailed by that decision. The decision to allocate ventilatory support for the Duchenne's patient may add considerable quality to his or her life and prolong that life by as much as ten years. 16 It will assuredly create burdens on caretakers that will increase proportionally as the disease progresses and enters its terminal stage. 5. Where various treatments need to be prioritized in

order to conserve financial resources. Here uncertainty may reside in the way the clinician determines priorities and how family members are included in the decision-making process. It is well recognized how the provider may project his or her values and priorities onto the patient and family, such as by prescribing treatment that the professional recommends but which may have debatable functional value (such as rigorous exercise regimen). 6. When significant risks are attached to treatment, but someone in authority demands that the treatment be administered. An example is surgical correction of

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certain deformities in a child with low-level functioning and little potential for improvement. Here the physician may be caught in the crossfire of his or her uncertainty about the benefits of the treatment, the need to retain the cooperation and good-will of the family, trying to spare the child as much discomfort as possible, and the ever present possibility that the absence of the surgery might retard the child's chances for functional gains later on in life. Uncertainty is a major clinical and ethical challenge facing pediatric rehabilitationists. The ability to creatively and effectively deal with it, remain open to alternatives and criticism, maintain confidence despite its inevitability, and accept whatever consequences materialize are constantly required. While the empirical sciences have mathematized uncertainty into an important body of knowledge, the specter of uncertainty in pediatric rehabilitation will more frequently sharpen the ethical sensibilities of the professional and his or her appreciation of rehabilitation as an art.

CASE SCENARIO In order to examine how various ethical principles mentioned above might apply to specific cases, consider the following scenario: Anne is a six-year-old who has had several strokes secondary to sickle cell anemia. She has considerable physical, cognitive, and language impairments, and lives with her mother in a rural area of the state. Dr. Jones has admitted Anne for rehabilitation on an annual basis for the last three years. On each readmission, Anne has shown significant functional decline compared to the functional levels she achieved at her previous discharge. On her most recent admission, for example, Anne had serious contractures, displayed excessive outbursts and disorderly behavior, and wore diapers despite having been bladder trained during the last rehabilitation. Anne's mother does not bring her back for checkups consistently, so Anne tends to

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get lost to followup. Anne's mother is unmarried but has had three children since Anne was born. The third-party payor is Medicaid. Although the rehabilitation team as well as the school system have had a Department of Family and Children's Services (DFACS) investigation on Anne's behalf; the investigation did not uncover any serious abuses or neglect by Anne's mother. Nevertheless, Dr. Jones is inclined to believe that Anne's condition will deteriorate once again after discharge and is beginning to doubt the advisedness of another round of intensive rehabilitation. Adding to jones's worries is the fact that Anne's rehabilitation usually lasts a month and is not nearly reimbursed by Medicaid. The rehabilitation center in which Jones works has suffered considerable financial setbacks over the last year and the administration has issued a strongly worded message to its staff that cost containment and working toward an "improved payor mix" will be top priorities over the next year. Dr. Jones wonders if she should admit Anne again. There is a natural inclination for one to believe that as long as Anne's circumstances remain the same, another intensive rehabilitation stay would be a waste of time and money. Tragically, life has dealt Anne a bad hand with seemingly little prospect of substantial improvement. Nevertheless, we should note that denying Anne rehabilitation would amount to penalizing her for circumstances utterly beyond her control. Both moral and clinical principles would urge that Anne receive rehabilitation, primarily because of her obvious need for it. From a justice standpoint, Anne did nothing to deserve her disability nor the possibly inadequate care she receives that compromises her gains in rehabilitation. Moral reasoning would therefore conclude that society ought to feel a moral compulsion to compensate Anne for these disadvantages that were none of her doing, rather than compound her problem by depriving her of care because of circumstances over which she has no control. 17 The inadequate Medicaid reimbursement is a less easy problem to grapple with because Dr. Jones's rehabilitation hospital does not have a duty to take a financial loss on the patients it admits

despite their need for care. Obviously, if hospitals admitted patients regardless of the adequacy of their health care insurance, those hospitals would risk financial ruin, whereupon no one could be treated, even those who could pay. A key factor in Anne's requiring periodic intensive rehabilitation is her mother, whose care of Anne may be less than responsible. Interestingly, though, while the mother's behavior to Anne may violate one of the ethical principles mentioned above-namely, that a parent ought not neglect a child to the point where the child's disability worsens due to that neglect-the DFACS investigation revealed no serious neglect. Consequently, an aura of uncertainty arises over the culpability of Anne's mother's behavior. Is Anne's deterioration inevitable despite her mother's best-and, under the circumstances, acceptable-efforts? Or was the DFACS's conclusion based on a slipshod investigation? Does DFACS utilize an ethically acceptable criterion for determining neglect or is it more influenced by an expedient one deriving from manpower and financial constraints? Should another investigation be requested or does this line of inquiry mistakenly blame the victim rather than seek to define and provide appropriate resources for Anne and her mother whereby they might both manage better? Despite the uncertainties posed by these questions, a benefits-burdens calculation would make one rather compelling observation: the current phenomenon of Anne's periodic readmissions for inpatient rehabilitation exert a heavy toll on her and an expensive toll on the Medicaid system and society's rehabilitation resources. Consequently, whatever burdens or inconveniences might accrue through less aggressive alternatives-such as more frequent medical and social work visits and follow-ups for Anne and her mother-are probably less oppressive than the burdens that result from the present situation. An aspect of the rehabilitation effort, then, would necessarily focus on providing Anne's mother with some degree of counseling and support whereby she might feel better equipped to care for Anne. Arrangements for Anne to periodically receive medical checkups so that she might retain and improve her functional levels rather than see them deteriorate would be indicated. Similarly, special training for

Ethical Issues in Pediatric Rehabilitation

Anne's teachers, especially by way of acquainting them with behavioral interventions they might employ when she acts inappropriately, would also be indicated. Obviously, these suggestions are easier to make than to carry through. If difficulties occur in their execution, it might be because of a lack of social commitment toward children with disability as well as fragmentation among the various care components that Anne requires. Obviously, for Anne's rehabilitation and life after rehabilitation to be successful, clinical, educational, and social work endeavors must be mutually supportive. Indeed, in Anne's case, they will either succeed or fail together. Consequently, cases like Anne's ultimately call upon our society'S political will to create adequate resources whereby her situation might brighten or, at least, not worsen. That such resources are still not nearly available enough perhaps attests to social attitudes that continue to regard citizens like Anne as outliers who do not thoroughly merit social membership and, therefore, are not qualified to access basic social goods whereby they might enjoy their lives.

CONCLUSION Ethical responses to dilemmas precipitated by children with disabilities issue from a mosaic of professional, legal, social, political, and technologic perspectives. IS Regardless of whoever has

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decisional authority, however, it is abundantly clear that the principal reference point and beneficiary of that decision making be the child. Social, parental, and professional norms demand that the child's welfare not be sacrificed or compromised for the mere convenience of others. This moral axiom is easier to preach than to practice, however, precisely because our moral obligations to the child with disability are not limitless. Factors such as limited resources, burdens on caregivers, treatments that present ambiguous benefits, and so forth may coalesce to create an authentic dilemma: that is, one where every available solution has a profoundly dark side that seriously compromises whatever attractiveness it would otherwise have. What is frequently of greatest difficulty in resolving dilemmas in pediatric rehabilitation is formulating a just and fair expectation from families as well as society in undertaking the care of children with disabilities. 19 We must recognize that if families are unable to carry through with their caretaking duties, then society is collectively responsible for assuming that duty. What form or definition that undertaking assumes will express the moral consciousness of our generation toward children that future social historians will comment on decades and centuries from now. The quintessential irony in formulating that definitionwhich returns this article to its initial observations about applying the best-interest standard to them-is the paradox of enabling the voices of children with disability to be heard.

REFERENCES 1. Rickham P. The ethics of surgery in newborn infants. Clin Pediat 1969; 8:251-253. 2. Hall MA, Ellman 1M. Health care law and ethics. St. Paul, MN: West Publishing Co., 1990, pp. 312-330. 3. Duff RS, Campbell AGM. Moral and ethical dilemmas in the special care nursery. N EnglJ Med 1973; 289:890-894. 4. Pence GE. Classic cases in medical ethics. New York: McGraw-Hill, 1990, pp. 136-163. 5. Buchanan AE, Brock DW. Deciding for others: the ethics of surrogate decision making. Cambridge, England: Cambridge University Press, 1989, pp. 112-126 and 215-266.

6. Holder AR. Legal issues in pediatric and adolescent medicine. New Haven: Yale University Press, 1985, pp. 82-145. 7. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics, 3rd Ed. New York: McGraw Hill, 1992, pp. 161-175. 8. Brody H. Contest terrain: In the best interests of . .. Hastings Cent Rep 1988; 18:37-40. 9. Arras J. Towards an ethic of ambiguity. Hastings Cent Rep 1984; 14:25-33. 10. Prince v. Massachusetts 321 US 158, 1943. 11. In re D.L.E., 645 P2d 271, Colo. 1982. 12. Leiken SL. An ethical issue in pediatric cancer care: nondisclosure of a fatal prognosis. In:

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Silber 'I: ed. Ethical issues in the treatment of children and adolescents. Thorofare, NJ: Slack, 1983, pp. 61-70. 13. Beresford EB. Uncertainty and the shaping of medical decisions. Hastings Cent Rep 1991; 21:6-11. 14. Peacock WJ, Standt LA. Spasticity in cerebral palsy and the selective posterior rhizotomy. j Child Neurol 1990; 5(3): 174-178. 15. Glenn MB, WhyteJ,eds. The practical management of spasticity in children and adults. Philadelphia: Lea & Febiger, 1990.

16. Bach JR, Campagnolo DI, Hoeman S. Life satisfaction of individuals with Duchenne muscular dystrophy using long-term mechanical ventilatory support. Am j Phys Med Rehabil 1991; 70:129-135. 17. Daniels N.just health care. Cambridge, England: Cambridge University Press, 1985. 18. Walzer M. Spheres of justice. New York: Basic Books, 1983. 19. Callahan D. Families as caregivers: the limits of morality. Arch Phys Med Refwbil 1988; 69:323-328.

Ethical issues in treating pediatric rehabilitation patients.

Ethical issues pertaining to treating pediatric rehabilitation patients stem from at least three sources: the fact that children are not morally auton...
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