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“Doctor, If This Were Your Child, What Would You Do?”

1999; American Academy of Pediatrics; Volume: 103; Issue: 1 Linguagem: Inglês

10.1542/peds.103.1.153

1098-4275

Robert D. Truog,

Child and Adolescent Health

Parents of seriously ill children are often faced with agonizing decisions about clinical treatment. These decisions concern not only whether to continue treatment or to allow their child to die, but also how much pain and suffering their child should experience in the hope that there will be survival and a good outcome. The enormous stress inherent in this type of situation is further compounded by the complexity and uncertainty that almost always accompanies the medical treatment of these children. In addition to trying to sort out their own views about the value of life and the meaning of suffering, parents must cope with medical data that are often confusing and conflicting, even to the clinicians themselves. It is quite natural, therefore, that difficult discussions between physicians and parents about these issues often culminate in the question, “Doctor, if this were your child, what would you do?”This question has a seductive appeal to physicians and parents alike. At a conference I recently attended on medical decision-making for critically ill children, I took a straw poll of the audience (mostly pediatricians) on how they would respond to this question from the parents of a critically ill child. The overwhelming majority indicated their willingness to provide a straightforward and candid answer to the question. When I began to raise some concerns about this mode of responding, some were clearly offended. For them, the issue seemed to strike deeply to some fundamental views about the proper role of pediatricians in decision-making. I have since reflected on some of the issues that are at stake for both parents and pediatricians when this question is asked.First, when parents ask this question they are making an important statement about their trust in the physician. In my own experience as a pediatric intensivist, I generally find this question from parents to be personally gratifying, as it represents an expression of their trust in my professional expertise and judgment. I imagine that most physicians experience satisfaction at having one's opinions valued, and perhaps followed. On hearing this question, physicians may feel more confident about making specific recommendations to the parents, and may feel that discussion of some of the more technical aspects of the child's treatment can be avoided, again because the parents seem willing to trust the clinician's decision-making. This in turn creates the opportunity for more intimate discussions, because now it may not be necessary to explain every detail and possible outcome in the way that might be required with more doubting or distrustful families.Second, at a time when many clinicians complain about the ever-increasing consumer model of medicine, this question expresses a genuine request for our “all things considered” opinion, beyond just our technical recommendations and analysis. In this sense, the question tends to restore our sense of value and worth as professionals. With so many patients today seeing their physicians as medical “vending machines,” dispensing whatever selections they desire, the expression of this question hearkens back to an older time when patients and families wanted more than just a physician's technical expertise.Third, this question relates to many of the values that are instilled in pediatricians during their training. House officers are often advised by attendings to treat their patients as if they were their own children. This is generally viewed as the highest standard to which a pediatrician can aspire. In addition to instilling a sense of responsibility, this view has the beneficial side effect of easing the clinicians' feelings of guilt when things do not go as well as hoped, because the clinicians can at least reassure themselves that their efforts were commensurate with what they would have done for their most precious loved ones.In addition to the physicians, parents also benefit by asking the question. First, the question expresses a willingness to openly recognize the physician as an authority on the treatment of seriously ill children, and to recognize that this knowledge and experience deserves respect, and even deference. In recognizing this role for the clinician, the moral burden and the awesome weight of profound decisions about their own child can then be at least partially shifted onto the shoulders of another.Second, the question can be seen as an invitation to the clinician to participate in the decision as more than just a medical expert. Asking the pediatrician what they would do if the patient were his or her own child is indeed a way of asking the doctor to think as if the patientactually were his or her own child. The question is an opportunity for the parents to personalize the encounter, and perhaps to gain assurance that the physician is deeply engaged in their child's care. In my experience, parents often breathe a sigh of relief when they learn I am the father of three children. I suspect it is because, at least in part, they believe this will make me more empathetic and engaged in sharing with them the experience of their child's illness. Perhaps they believe that at least I will be better able to imagine their suffering, even if I have never been in their shoes.With all these emotional incentives aligned behind a need for parents to ask the question and a desire for the pediatrician to answer it, what could possibly be the problem? An important but often overlooked distinction between the types of advice we give to parents is that between medical facts and individual values. Although pediatricians are expected to be experts on questions of medical fact, we can make no such claim when it comes to the values and preferences of individuals or families. Although pediatricians tend to be quite sensitive to this issue when dealing with families from obviously different cultural or religious backgrounds, the potential for error is actually much greater when working with families from backgrounds similar to our own, where there is a strong temptation to assume (for both the physician and the parents alike) that important views and preferences are shared. We know from the literature on advance directives that even spouses can have significantly inaccurate views about each others' preferences for life-sustaining treatments1; certainly the potential for error is even greater in relationships between pediatricians and families.These differences between medical facts and family values are not universally acknowledged, however. On the one hand, some physicians argue that their extensive experience with caring for sick children does indeed give them legitimate expertise in questions of value, and insist that they should be seen as an authority on such questions as whether or not to discontinue life support for a critically ill child. Furthermore, they argue, families are exceedingly stressed at times of such crisis, and are unable to make clear decisions on their own. According to this view, physicians are shirking their responsibility to both the parents and the child if they fail to make firm recommendations about the right way to proceed under the circumstances.Others also discount this distinction between facts and values, but from an opposite set of assumptions.2 They argue that there are no such things as a medical “facts,” there are only medical “opinions.” According to this perspective, physicians usually forget that their view of the world emerges from a Western scientific tradition, and that the premises of this world view are not shared across all cultures or individuals. In its extreme form, even diagnoses like meningitis or dehydration are based on a uniquely Western model of illness and disease, and hide assumptions that clinicians must not take for granted.I believe that both of these views miss the mark. Certainly there is a gray zone (eg, should a pediatrician encourage or discourage the use of herbal medicine by an Asian family who believes in its efficacy?); however, the fact that a gray zone exists should not lead us to believe that the differences between facts and values are impossible to distinguish, no more than the existence of dusk implies that we can not differentiate between daytime and nighttime. Physicians should see themselves as experts in the realm of medical science, and should be as bold and authoritative as the facts allow in discussing issues of diagnosis and prognosis with parents. They must be cautious and sensitive, however, when moving into the territory of interpreting these facts, of explaining their meaning, and of translating these understandings into medical decisions.In other words, when dealing with questions of value, physicians should see their role to be facilitative rather then directive. Being nondirective, however, is not the same as being silent. An excellent model for this type of interaction is that of the psychotherapist. Psychiatry has taught us that there is no such thing as a “neutral” therapist. Complete objectivity is impossible between a physician and parent when discussing value-laden questions like whether to withdraw life support. Countertransference is the general term for describing the beliefs, prejudices, and feelings that the clinician brings to the discussion. Just as a good therapist would rarely, if ever, give a direct answer to the question, “Now tell me doctor, if you were me, would you divorce my wife?”, so should pediatricians be reluctant to provide direct answers to similarly profound questions from parents. The job of the clinician in this case is to guide the patient or parent to a choice that is authentic and genuine for them. When parents are too stressed to be able to articulate or even perceive their core values and beliefs, they will often benefit from the input of family, friends, clergy, or other supportive individuals who know them well.In a broader sense, the response to the question, “If this were your child, what would you do?” concerns the much more general and controversial area of defining boundaries between clinicians, patients, and their families.3 One extreme view, sometimes articulated in psychiatry, is that the clinician must be a “blank slate” revealing essentially nothing about one's person beyond one's bare appearance. This view is unnecessarily restrictive, especially in pediatrics, and diminishes the value of the medical encounter for the pediatrician and family alike. To have the freedom to be open and to reach out emotionally to the parents of ill children is one of the most cherished aspects of pediatric practice for many clinicians, and certainly a perspective that is equally valued by many families.To give an example of the complexities involved in defining these boundaries, consider the dilemma of a pediatric oncologist who has endured the experience of having a child with cancer. To what degree should this clinician be self-revealing in interactions with the parents of a patient newly diagnosed with cancer? When should the pediatrician reveal that he or she has personal knowledge of their situation? Does it depend on whether or not the physician's child survived? Does it depend on the degree to which the physician “identifies” with the parents at an intellectual, emotional, or socioeconomic level? These are difficult questions, without easy answers. Intuitions here can play an important role, just as they do in deciding whether a child with a fever has a trivial infection or is seriously ill. Just as in clinical practice, however, these intuitions need to be guided and informed by a fairly sophisticated understanding of the complex issues involved. Knowing when and how to reveal one's personal experiences and views is part of the art of medicine, a part that both allows us to experience the deep gratifications of clinical practice while assuring a true respect for the differences between us, our patients, and their families.I thank Dr Richard Martinez for his useful insights into the complexities of defining boundaries in relationships between physicians, patients, and their families.