Ethics and children failing to thrive'

1
Ethics and children failing to thrive.

• Guidelines, lifeline or snake in the grass

2
Nothing divides us like FTT

• It involves little children
• our hearts have been touched by fire
• It should be soluble
• So much work, and measurable failure
• Our identities are ties up with this
• Complexity
• There are real harms, and asymmetry of perception
  interagency, between colleagues

3
What stands between us

• When two well informed and well-intentioned
  professionals cannot agree about the best thing
  to do, or the best way to approach a problem,
  often the difference between them is not a matter
  of expertise, but a difference in ethical
  viewpoint.

4
Ethics yet another problem

• Secular, liberal, pluralist society
• Genuine ethical disagreement
• Scepticism relativism
• The role of culture (cf. FGM)
• Inarticulacy about ethics, frameworks
• Yet values ? shape our evaluations

5
Ethical Frameworks

• Consequentialism
• Deontological (duty) approaches
• Virtue-based ethics
• Others
• Rights-based approaches
• Ethic of Care
• Narrative Ethics

6
Deontological approaches

• Focus on what you do (acts)
• Acts can be intrinsically right or wrong
• Ends dont justify the means
• Duties not to do things
• Distinction between intention and foresight
• Various problems

7
Consequentialism

• Focus on outcome consequences
• Powerful appeal
• Simple, elegant
• Impartial
• Practical
• Objective ? quantifiable
• Various objections
• Dominate public and social policy

8
Virtue-based Ethics

• Focus on the character of the agent
• Virtues Reasoned, thoughtful capacities
• Produce dispositions to choose or act
• Tied to human well-being flourishing
• Shape ones practical reasoning
• What would the virtuous person do?
• Problems indeterminacy ?acts ?outcomes
• Reflective equilibrium - ?

9
Principlism

• Beauchamp and Childress
• Four principles
• Autonomy
• Beneficence
• Non-maleficence
• Justice
• Common framework and language
• Four Principles plus Scope

10
Problems of Principlism

• Dominates Bioethics literature and debate
• A generation of clinicians
• Doesnt solve problems motherhood
• Abstract principles
• Not action-guiding left with dilemmas
• Primacy of Autonomy - Not here surely

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Whats the point?

• Understand our disagreements
• Basis of respect rather than dissention
• Ethical disagreement ? reflection
• Could an ethical problem solving approach be
  useful with FTT issues?
• If

12
Complexity

• Reductionism as a tool of analysis
• The HIV example
• Conceptual misunderstanding ? the wrong track
• Complexity is disabling
• Clarity about tasks and problems
• Do what you can, not what you cant

13
Rob Rosebys points

• A childs place is at home with her family
• Hospitals are expensive
• Hospitals are dangerous
• Risk vs Benefit Calculations

14
Hospitals are dangerous

• Nosoconial infections
• Other harms may be more important
• Away from home, family support
• Disrupts relationships basis of care
• Changes the way you are seen
• Undermines self-trust, autonomy
• Stresses someone whos already struggling
• What can they do? What cant they do?

15
Ethical Dilemmas

• Hegel The clash of Right and Right
• Geoffrey Sayer-McCord Are there any such thing
  as ethical dilemmas
• Maybe there only appear to be moral dilemmas
• The right choice vs a reasonable thing
• Excellence as the enemy of the good.

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The knowledge problem

• What is the patients best interest
• Legitimate, but conflicting interests
• More than one person has interests
• Imperfect knowledge, complexity
• Indeterminacy
• Culture different worlds of meaning
• FTT is just a symptom anyway

17
Attitudes

• Humility
• Respect
• Compassion vs efficiency
• Reasonable vs perfection
• Kick high and follow through
• Time its a process not an event
• Foster (not undermine) autonomy

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Remember

• You are a servant not a crusader
• The focus is on the wellbeing of the family, not
  you
• Clarity dont get lost in the process
• Collaboration requires time.
• If you are stuck or at loggerheads
• ask what you are missing? (the baby story)

19
Case study group discussion

• 5 groups of six
• The case of Antjupali (fictitious)
• Read case 5 minutes to make notes
• 20 minutes of discussion
• Then a period for feedback.

20
Ethically-sound decision-making

• Get the facts straight medical clarity
• What are the ethically-salient features of the
  situation
• Make sure the right people are involved
• What are the implications of each choice
• What values or principles might guide the
  decision
• Has there been time for the decision to mature
• Dont get in the way.