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Bart A, Hall GA, Gillam L. Gillick competence: an inadequate guide to the ethics of involving adolescents in decision-making. JOURNAL OF MEDICAL ETHICS 2024; 50:157-162. [PMID: 37169548 DOI: 10.1136/jme-2023-108930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
Developmentally, adolescence sits in transition between childhood and adulthood. Involving adolescents in their medical decision-making prompts important and complex ethical questions. Originating in the UK, the concept of Gillick competence is a dominant framework for navigating adolescent medical decision-making from legal, ethical and clinical perspectives and is commonly treated as comprehensive. In this paper, we argue that its utility is far more limited, and hence over-reliance on Gillick risks undermining rather than promoting ethically appropriate adolescent involvement. We demonstrate that Gillick only provides guidance in the limited range of cases where legal decisional authority needs to be clarified. The range of cases where use of Gillick actually promotes adolescent involvement is narrower still, because several features must be present for Gillick to be enacted. Each of these features can, and do, act as barriers to adolescent involvement. Within these limited situations, we argue that Gillick is not specific or strong enough and is reliant on ethically contestable principles. Moreover, in most situations in adolescent healthcare, Gillick is silent on the ethical questions around involving adolescents. This is because it focuses on decisional authority-having the final say in decision-making-which is one small subset of the many ways adolescents could be involved in decision-making. The implication of our analysis is that use of Gillick competence tends to limit or undermine adolescent involvement opportunities. We propose that those working with adolescents should be judicious in seeking Gillick's guidance, instead drawing on and developing alternative frameworks that provide a comprehensive model for adolescent involvement.
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Affiliation(s)
- Avraham Bart
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Georgina Antonia Hall
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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März JW. What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare? Eur J Pediatr 2022; 181:3805-3816. [PMID: 36083315 PMCID: PMC9546983 DOI: 10.1007/s00431-022-04609-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022]
Abstract
The present review analyses the implications of the best interests of the child principle, which is one of the most widely discussed principles of medical ethics and human rights, for paediatric healthcare. As a starting point, it presents the interpretation of the best interests principle by the United Nations Committee on the Rights of the Child. On this basis, it points out possible fields of application of the best interests principle with regard to paediatric healthcare and discusses the potential difficulties in the application of the best interests principle. Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing. Conclusion: The best interests principle requires action, inter alia, by health policymakers, professional associations, hospital managers and medical teams to ensure children receive the best possible healthcare. Whilst the best interests principle does not provide a conclusive solution to all ethical dilemmas in paediatric healthcare (as illustrated by the case studies), it provides children, medical teams, parents and families, and clinical ethicists with an indispensable framework for health care centred on the rights of the child. What is Known: • The best interests principle is one of the most widely discussed principles of medical ethics and human rights and one of the four general principles of the Convention on the Rights of the Child. What is New: • The present review discusses possible fields of application and potential difficulties of the best interests principle with regard to paediatric healthcare. • Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.
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Affiliation(s)
- Julian W. März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
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Livingston J, Di-Mola M, Lowry J, Ruse N, Chiang KY, Chopra Y, Schechter T, Ali M, Licht C, Wall D, Krueger J. Peripheral venous catheter collection of immune effector cells and hematopoietic stem cells is feasible and safe in older pediatric patients. Transfusion 2021; 61:3413-3419. [PMID: 34751944 DOI: 10.1111/trf.16717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Collection of hematopoietic stem cells (HSC) and immune effector cells (IEC) has unique challenges in children. To maintain adequate blood flow, central venous catheters (CVCs) remain the standard of care in many centers, but are associated with procedural risks and increased resource utilization. The goal of this study was to determine feasibility and safety of peripheral venous catheter (PVC) cell collection in older children. METHODS Patients and donors requiring venous access with weight >25 kg, age >8 years were screened for PVC collection via 18G PVCs. Those with poor venous access (on history/exam/pre-screening ultrasound) or unable to maintain suitable procedural position were excluded. Comparison was made to CVC collections in a matched patient cohort. RESULTS Thirty-eight individuals were screened and met age/weight criteria for PVC collection. Five did not have PVC collection attempted due to poor access (n = 4) or behavioral concerns (n = 1). Thirty-three had PVC collection attempt (HSC = 22; IEC = 11) with median age 15.3 year (range 9.7-18.0) and weight 58.5 kg (range 27.9-115.4). Thirty-two of 33 (97%) patients were collected successfully by PVC without adverse events. Comparing PVC to matched CVC collection cohort (n = 18), there was no significant difference in flow rate (48.2 mL/h vs 53.9 mL/h, p = 0.12), collection time (266 min vs 262 min, p = 0.85) or collection efficiency (IEC/CD3 60.9% vs 60.8% p = 0.99; HSC/CD34 53.6% vs 41.3% p = 0.05). CONCLUSION PVC collection of HSC and IEC is feasible and safe in older children with comparable collection efficiency to CVC collections. Ultrasound screening may reduce failure rates. PVC collections can reduce the risk of CVC insertions and associated healthcare costs.
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Affiliation(s)
- Joel Livingston
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Maria Di-Mola
- Dialysis and Apheresis Program, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Lowry
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nigel Ruse
- Vascular Access Service, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kuang-Yueh Chiang
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Yogi Chopra
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Tal Schechter
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Ali
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada.,Dialysis and Apheresis Program, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donna Wall
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Joerg Krueger
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, The University of Toronto, Toronto, Ontario, Canada
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Eyrich M, Schulze H. HLA Matching in Pediatric Stem Cell Transplantation. Transfus Med Hemother 2019; 46:348-355. [PMID: 31832060 DOI: 10.1159/000502422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/23/2019] [Indexed: 12/22/2022] Open
Abstract
For several malignant and nonmalignant disorders such as leukemias, lymphomas, or inborn errors of hematopoiesis, stem cell transplantation is the only curative option. Depending on the underlying cause of the disease, the conditioning regimens, source of the stem cells, and graft composition may vary. Possible stem cell donors are selected from databases considering existing major histocompatibility genes of the donor and the recipient. This is currently performed by matching human leukocyte antigen (HLA)-A, -B, and -C for class I, as well as HLA-DRB1 and -DQB1 for class II. Stem cell transplantation for nonmalignant disorders is a specialty of pediatrics. While algorithms for donor selection in these cases are generally similar, the objective of optimizing a possible graft-versus-leukemia effect is less important. In this article, we aim to provide an overview on the current methods for HLA typing and the algorithms for HLA matching. We also address ethical aspects regarding children and minors as stem cell donors.
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Affiliation(s)
- Matthias Eyrich
- University Children's Hospital, University Hospital Würzburg, Würzburg, Germany
| | - Harald Schulze
- Institute of Experimental Biomedicine, Chair I, University Hospital Würzburg, Würzburg, Germany
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