Portal de Periódicos da CAPES

Ethics in Everyday Pediatrics

2009; Elsevier BV; Volume: 154; Issue: 6 Linguagem: Inglês

10.1016/j.jpeds.2009.02.021

1097-6833

Robert M. Jacobson, Ryan M. Antiel, Philip R. Fischer,

Child and Adolescent Health

In pediatric practice, ethical implications are frequently considered with end-of-life care, research, and genomic screening. Less often recognized, however, are the substantial ethical concerns that regularly arise within general pediatric practice. In this brief commentary, we wish to draw attention to the ethical questions underlying common clinical situations and provide some framework to guide our deliberations.Non-Evidenced-Based CareAlthough primary care pediatricians have suggested that only 20% of their practice can be supported by data,1Rudolf M.C. Jones K. Attitudes to questioning in clinical practice may be changed.BMJ. 1998; 316: 1535-1536Crossref PubMed Google Scholar a subsequent study reported a more reassuring 50%.2Rudolf M.C.J. Lyth N. Bundle A. Rowland G. Kelly A. Bosson S. et al.A search for the evidence supporting community paediatric practice.Arch Dis Child. 1999; 80: 257-261Crossref PubMed Scopus (35) Google Scholar Still that leaves the glass, at best, only half-full. Is prescribing unproven therapies unethical? A key aspect of medical ethics is that care must be beneficent; it must be good for patients. In addition to our traditional approaches that lack an evidence base, more and more practitioners are offering similarly unsupported recommendations for complementary and alternative medicines.Unproven therapies may misdirect efforts that the provider or parents might otherwise make. All therapies are associated with some expenditure of resources. Given limited resources, those spent on 1 therapy mean resources not available for another. Wasted resources endanger opportunities for helpful remedies for the individual patient, as well as for others. Furthermore, offering therapies absent supporting evidence falsely raises hopes and potentially deceives both parent and child. These surely violate the ethical principle of nonmaleficence.Parental ChoiceAnd what do we do with parents who refuse our evidence-based recommendations? Most pediatricians would judge refusal of insulin therapy for a diabetic child as medical neglect. But how should we judge the more commonplace refusal of routine vaccination? We routinely encounter parents who refuse flu vaccines for their children or themselves. It is highly unlikely that a primary care provider would report a family to legal authorities for failure to vaccinate as evidence of medical neglect. Still, some pediatricians refuse to see a patient because the parents refuse vaccinations. Others accommodate the parents, stating that the parents, in the end, must be responsible and have control over the medical decision-making for their children. But, on the basis of the evidence now available, refusal to vaccinate puts a child in harm's way, not to mention the child's contacts. Although medical providers might appeal to the ethical principle of autonomy, this must be balanced with the principle of nonmaleficence.Enhancing HeightQuite possibly without any thought or consideration, pediatricians roundly express approval to the parents when children are discovered to measure above average in height. Is it better to be taller? To paraphrase Indiana humorist “Kin” Hubbard, “It is no disgrace to be short, but it might as well be.” A meta-analysis showed that physical height relates positively to social esteem, leader emergence, performance, and income.3Judge T.A. Cable D.M. The effect of physical height on workplace success and income: preliminary test of a theoretical model.J Appl Psychol. 2004; 89: 428-441Crossref PubMed Scopus (448) Google Scholar Best-selling author Malcolm Gladwell compared U.S. males with CEOs of Fortune 500 companies and found that the general population is 3″ shorter than CEOs, and although only 4% of American men are over 6′ 2″, a full 30% of CEOs are taller than 6′ 2″.4Gladwell M. Blink: the power of thinking without thinking. Little, Brown and Company, New York2005Google Scholar Furthermore, each inch of increased height is associated with an annual salary increase of $789; wages are 2.6% higher for each additional inch of height at age 16.5Persico N. Postlewaite A. Silverman D. The effect of adolescent experience on labor market outcomes: the case of height.J Political Economy. 2004; 112: 1019-1053Crossref Scopus (330) Google ScholarGrowth hormone injections help increase height in children with pathologic conditions such as growth hormone deficiency, Turner syndrome, and chronic kidney failure. Growth hormone treatment can increase short-term growth and can increase subsequent adult height by 4 to 6 cm, which in 2002 corresponded to treatment costs of $35 000 per inch.6Finkelstein B.S. Imperiale T.F. Speroff T. Marrero U. Radcliffe D.J. Cuttler L. Effect of growth hormone therapy on height in children with idiopathic short stature.Arch Pediatr Adolesc Med. 2002; 156: 230-240Crossref PubMed Scopus (27) Google Scholar Is this cost prohibitive, or does the resulting psychological and social gain make growth hormone therapy a worthwhile investment?Is it ethical to put a normal but short child through the therapy and its attendant risks? What about the ethical principle of justice? Is it just to consider height enhancement for children whose insurance covers the treatment and not for others?Enhancing Academic and Athletic PerformanceAs pediatricians, we encourage growing children and adolescents to maintain appropriate balance between eating, sleeping, and activities, so they will perform well in school and sports. Some adolescents choose to use nutritional supplements such as creatine to further improve their performance.Athletes use a variety of performance-enhancing substances. Is it less acceptable for a child than an adult to use such substances? Is it more ethical for a body builder to chemically enhance muscle growth than a professional baseball player? What principles should guide adolescent athletes?Nine percent to 20% of adolescents reportedly use prescription medications as “study aids,” even though those medications had been prescribed for someone else.7Carroll B.C. McLaughlin T.J. Blake D.R. Patterns and knowledge of nonmedical use of stimulants among college students.Arch Pediatr Adolesc Med. 2006; 160: 481-485Crossref PubMed Scopus (58) Google Scholar Interestingly, educators and scientists are also debating their own use of cognition enhancers.8Sahakian B. Morein-Zamir S. Professor's little helper.Nature. 2007; 450: 1157-1159Crossref PubMed Scopus (259) Google Scholar Indeed, if methylphenidate improves attention even in individuals without attention deficit–hyperactivity disorder, why is it wrong to take methylphenidate to improve late-night studying? If we use illegality as a reason, would it be ethical to take the medication during a study-abroad semester in a country where it is not illegal? Is it the cost ($3 to $15 per methylphenidate pill in some areas) that makes it unethical? Or is it because use confers an unfair disadvantage on those who did not use a stimulant and are graded on the same curve as users? Practice is not necessarily just when one patient's competitive enhancements push other children further below the mean.Cosmetic EnhancementsHow much enhancement of normal variations in physical appearance is ethically appropriate? What about orthodontic appliances (braces) in situations that do not influence chewing or dental health? How much variation in tooth spacing is acceptable? If correction of imperfect dental appearance is good and ethically appropriate for affluent and insured children, should it be available to all children? Does a society's choice to allow “better smiles” for only some children make untreated children fall farther below the “normal” range and further compromise their potential for success in life?Similar questions can be applied to mole removal, laser treatment of hemangiomas, treatment of persistent male gynecomastia, body-piercing, and tattooing. Risks and benefits include psychological factors, as well as physical considerations. At what age should a child have independent decision-making responsibility to choose procedures that alter or manipulate physical appearance? When are physical stigmata of a disease or injury or physiological process “deformities” to be considered as medical conditions and when are they not? The ethical principle of dignity holds that we should appropriately regard our patients. Our treatment might not be ethically appropriate if it depends upon a notion that physical appearance is a major determinant of a child's worth.DiscussionClearly, ethical concerns can be raised about much of what occurs in everyday pediatric practice. The well-recognized principles of beneficence, nonmaleficence, justice, autonomy, and dignity apply but create tension. Attention to several themes can frame our thoughts as we navigate amidst ethical issues in our everyday practices:(1) Ethical issues are important to common aspects of pediatric practice. Identifying and recognizing these issues, we should acknowledge that our actions are influenced by our underlying beliefs. Do we view our professional role as treating illness and restoring health (as in the traditional view of “medical care”)? Or, do we see our role as enhancing the health of individuals so they can advance beyond their current normative level? (2) Biotechnology will permit advances and opportunities that may not be appropriate, affordable, or evidence-based. We should acknowledge that many practices are currently unproven and that we and our patients' families may have different views of the acceptability of various risks (maleficence) and benefits (beneficence) associated with unproven interventions. (3) Normal distributions reflect variations of normality. Not all children will be, could be, or should be above average. We should recognize that each time we attempt to enhance 1 patient, we leave untreated patients at a relative disadvantage. In addition, advocating for expensive enhancements in appearance could be interpreted as subtly implying that a child's emerging dignity depends more on appearance than on character. (4) Not all issues regarding one's physical or mental comfort are necessarily medical issues. Life includes struggles, and some struggles serve as the substrate for character development. As care providers, we should decide how much to emphasize avoidance of difficulty and how much to foster positive personal development of dignity through adversity. (5) All medical interventions carry potential for expense, adverse consequences, and failure, and we must recognize that benefits, costs, and risks of interventions might be differentially applied to children, as compared with their parents. (6) Parental desires are malleable by education, and pediatricians may be in an optimal position to teach. Perhaps we can even help shape society. Does our introductory small talk during office visits focus on appearance and achievement? We might better instead focus on well-being and adjustment.As pediatricians, we deal daily with our world's next generation. We must remain mindful of the ethical implications of our professional behavior. We should consider how we make “medical” cost-benefit decisions regarding elective and cosmetic enhancement interventions. We should seek to consider secondary effects on nontreated patients who will be relatively more disadvantaged by not being included among the treated few. As biotechnology advances and as social pressures evolve, we should thoughtfully strive to ensure that our patients are receiving truly ethical care.References available atwww.jpeds.com. In pediatric practice, ethical implications are frequently considered with end-of-life care, research, and genomic screening. Less often recognized, however, are the substantial ethical concerns that regularly arise within general pediatric practice. In this brief commentary, we wish to draw attention to the ethical questions underlying common clinical situations and provide some framework to guide our deliberations. Non-Evidenced-Based CareAlthough primary care pediatricians have suggested that only 20% of their practice can be supported by data,1Rudolf M.C. Jones K. Attitudes to questioning in clinical practice may be changed.BMJ. 1998; 316: 1535-1536Crossref PubMed Google Scholar a subsequent study reported a more reassuring 50%.2Rudolf M.C.J. Lyth N. Bundle A. Rowland G. Kelly A. Bosson S. et al.A search for the evidence supporting community paediatric practice.Arch Dis Child. 1999; 80: 257-261Crossref PubMed Scopus (35) Google Scholar Still that leaves the glass, at best, only half-full. Is prescribing unproven therapies unethical? A key aspect of medical ethics is that care must be beneficent; it must be good for patients. In addition to our traditional approaches that lack an evidence base, more and more practitioners are offering similarly unsupported recommendations for complementary and alternative medicines.Unproven therapies may misdirect efforts that the provider or parents might otherwise make. All therapies are associated with some expenditure of resources. Given limited resources, those spent on 1 therapy mean resources not available for another. Wasted resources endanger opportunities for helpful remedies for the individual patient, as well as for others. Furthermore, offering therapies absent supporting evidence falsely raises hopes and potentially deceives both parent and child. These surely violate the ethical principle of nonmaleficence. Although primary care pediatricians have suggested that only 20% of their practice can be supported by data,1Rudolf M.C. Jones K. Attitudes to questioning in clinical practice may be changed.BMJ. 1998; 316: 1535-1536Crossref PubMed Google Scholar a subsequent study reported a more reassuring 50%.2Rudolf M.C.J. Lyth N. Bundle A. Rowland G. Kelly A. Bosson S. et al.A search for the evidence supporting community paediatric practice.Arch Dis Child. 1999; 80: 257-261Crossref PubMed Scopus (35) Google Scholar Still that leaves the glass, at best, only half-full. Is prescribing unproven therapies unethical? A key aspect of medical ethics is that care must be beneficent; it must be good for patients. In addition to our traditional approaches that lack an evidence base, more and more practitioners are offering similarly unsupported recommendations for complementary and alternative medicines. Unproven therapies may misdirect efforts that the provider or parents might otherwise make. All therapies are associated with some expenditure of resources. Given limited resources, those spent on 1 therapy mean resources not available for another. Wasted resources endanger opportunities for helpful remedies for the individual patient, as well as for others. Furthermore, offering therapies absent supporting evidence falsely raises hopes and potentially deceives both parent and child. These surely violate the ethical principle of nonmaleficence. Parental ChoiceAnd what do we do with parents who refuse our evidence-based recommendations? Most pediatricians would judge refusal of insulin therapy for a diabetic child as medical neglect. But how should we judge the more commonplace refusal of routine vaccination? We routinely encounter parents who refuse flu vaccines for their children or themselves. It is highly unlikely that a primary care provider would report a family to legal authorities for failure to vaccinate as evidence of medical neglect. Still, some pediatricians refuse to see a patient because the parents refuse vaccinations. Others accommodate the parents, stating that the parents, in the end, must be responsible and have control over the medical decision-making for their children. But, on the basis of the evidence now available, refusal to vaccinate puts a child in harm's way, not to mention the child's contacts. Although medical providers might appeal to the ethical principle of autonomy, this must be balanced with the principle of nonmaleficence. And what do we do with parents who refuse our evidence-based recommendations? Most pediatricians would judge refusal of insulin therapy for a diabetic child as medical neglect. But how should we judge the more commonplace refusal of routine vaccination? We routinely encounter parents who refuse flu vaccines for their children or themselves. It is highly unlikely that a primary care provider would report a family to legal authorities for failure to vaccinate as evidence of medical neglect. Still, some pediatricians refuse to see a patient because the parents refuse vaccinations. Others accommodate the parents, stating that the parents, in the end, must be responsible and have control over the medical decision-making for their children. But, on the basis of the evidence now available, refusal to vaccinate puts a child in harm's way, not to mention the child's contacts. Although medical providers might appeal to the ethical principle of autonomy, this must be balanced with the principle of nonmaleficence. Enhancing HeightQuite possibly without any thought or consideration, pediatricians roundly express approval to the parents when children are discovered to measure above average in height. Is it better to be taller? To paraphrase Indiana humorist “Kin” Hubbard, “It is no disgrace to be short, but it might as well be.” A meta-analysis showed that physical height relates positively to social esteem, leader emergence, performance, and income.3Judge T.A. Cable D.M. The effect of physical height on workplace success and income: preliminary test of a theoretical model.J Appl Psychol. 2004; 89: 428-441Crossref PubMed Scopus (448) Google Scholar Best-selling author Malcolm Gladwell compared U.S. males with CEOs of Fortune 500 companies and found that the general population is 3″ shorter than CEOs, and although only 4% of American men are over 6′ 2″, a full 30% of CEOs are taller than 6′ 2″.4Gladwell M. Blink: the power of thinking without thinking. Little, Brown and Company, New York2005Google Scholar Furthermore, each inch of increased height is associated with an annual salary increase of $789; wages are 2.6% higher for each additional inch of height at age 16.5Persico N. Postlewaite A. Silverman D. The effect of adolescent experience on labor market outcomes: the case of height.J Political Economy. 2004; 112: 1019-1053Crossref Scopus (330) Google ScholarGrowth hormone injections help increase height in children with pathologic conditions such as growth hormone deficiency, Turner syndrome, and chronic kidney failure. Growth hormone treatment can increase short-term growth and can increase subsequent adult height by 4 to 6 cm, which in 2002 corresponded to treatment costs of $35 000 per inch.6Finkelstein B.S. Imperiale T.F. Speroff T. Marrero U. Radcliffe D.J. Cuttler L. Effect of growth hormone therapy on height in children with idiopathic short stature.Arch Pediatr Adolesc Med. 2002; 156: 230-240Crossref PubMed Scopus (27) Google Scholar Is this cost prohibitive, or does the resulting psychological and social gain make growth hormone therapy a worthwhile investment?Is it ethical to put a normal but short child through the therapy and its attendant risks? What about the ethical principle of justice? Is it just to consider height enhancement for children whose insurance covers the treatment and not for others? Quite possibly without any thought or consideration, pediatricians roundly express approval to the parents when children are discovered to measure above average in height. Is it better to be taller? To paraphrase Indiana humorist “Kin” Hubbard, “It is no disgrace to be short, but it might as well be.” A meta-analysis showed that physical height relates positively to social esteem, leader emergence, performance, and income.3Judge T.A. Cable D.M. The effect of physical height on workplace success and income: preliminary test of a theoretical model.J Appl Psychol. 2004; 89: 428-441Crossref PubMed Scopus (448) Google Scholar Best-selling author Malcolm Gladwell compared U.S. males with CEOs of Fortune 500 companies and found that the general population is 3″ shorter than CEOs, and although only 4% of American men are over 6′ 2″, a full 30% of CEOs are taller than 6′ 2″.4Gladwell M. Blink: the power of thinking without thinking. Little, Brown and Company, New York2005Google Scholar Furthermore, each inch of increased height is associated with an annual salary increase of $789; wages are 2.6% higher for each additional inch of height at age 16.5Persico N. Postlewaite A. Silverman D. The effect of adolescent experience on labor market outcomes: the case of height.J Political Economy. 2004; 112: 1019-1053Crossref Scopus (330) Google Scholar Growth hormone injections help increase height in children with pathologic conditions such as growth hormone deficiency, Turner syndrome, and chronic kidney failure. Growth hormone treatment can increase short-term growth and can increase subsequent adult height by 4 to 6 cm, which in 2002 corresponded to treatment costs of $35 000 per inch.6Finkelstein B.S. Imperiale T.F. Speroff T. Marrero U. Radcliffe D.J. Cuttler L. Effect of growth hormone therapy on height in children with idiopathic short stature.Arch Pediatr Adolesc Med. 2002; 156: 230-240Crossref PubMed Scopus (27) Google Scholar Is this cost prohibitive, or does the resulting psychological and social gain make growth hormone therapy a worthwhile investment? Is it ethical to put a normal but short child through the therapy and its attendant risks? What about the ethical principle of justice? Is it just to consider height enhancement for children whose insurance covers the treatment and not for others? Enhancing Academic and Athletic PerformanceAs pediatricians, we encourage growing children and adolescents to maintain appropriate balance between eating, sleeping, and activities, so they will perform well in school and sports. Some adolescents choose to use nutritional supplements such as creatine to further improve their performance.Athletes use a variety of performance-enhancing substances. Is it less acceptable for a child than an adult to use such substances? Is it more ethical for a body builder to chemically enhance muscle growth than a professional baseball player? What principles should guide adolescent athletes?Nine percent to 20% of adolescents reportedly use prescription medications as “study aids,” even though those medications had been prescribed for someone else.7Carroll B.C. McLaughlin T.J. Blake D.R. Patterns and knowledge of nonmedical use of stimulants among college students.Arch Pediatr Adolesc Med. 2006; 160: 481-485Crossref PubMed Scopus (58) Google Scholar Interestingly, educators and scientists are also debating their own use of cognition enhancers.8Sahakian B. Morein-Zamir S. Professor's little helper.Nature. 2007; 450: 1157-1159Crossref PubMed Scopus (259) Google Scholar Indeed, if methylphenidate improves attention even in individuals without attention deficit–hyperactivity disorder, why is it wrong to take methylphenidate to improve late-night studying? If we use illegality as a reason, would it be ethical to take the medication during a study-abroad semester in a country where it is not illegal? Is it the cost ($3 to $15 per methylphenidate pill in some areas) that makes it unethical? Or is it because use confers an unfair disadvantage on those who did not use a stimulant and are graded on the same curve as users? Practice is not necessarily just when one patient's competitive enhancements push other children further below the mean. As pediatricians, we encourage growing children and adolescents to maintain appropriate balance between eating, sleeping, and activities, so they will perform well in school and sports. Some adolescents choose to use nutritional supplements such as creatine to further improve their performance. Athletes use a variety of performance-enhancing substances. Is it less acceptable for a child than an adult to use such substances? Is it more ethical for a body builder to chemically enhance muscle growth than a professional baseball player? What principles should guide adolescent athletes? Nine percent to 20% of adolescents reportedly use prescription medications as “study aids,” even though those medications had been prescribed for someone else.7Carroll B.C. McLaughlin T.J. Blake D.R. Patterns and knowledge of nonmedical use of stimulants among college students.Arch Pediatr Adolesc Med. 2006; 160: 481-485Crossref PubMed Scopus (58) Google Scholar Interestingly, educators and scientists are also debating their own use of cognition enhancers.8Sahakian B. Morein-Zamir S. Professor's little helper.Nature. 2007; 450: 1157-1159Crossref PubMed Scopus (259) Google Scholar Indeed, if methylphenidate improves attention even in individuals without attention deficit–hyperactivity disorder, why is it wrong to take methylphenidate to improve late-night studying? If we use illegality as a reason, would it be ethical to take the medication during a study-abroad semester in a country where it is not illegal? Is it the cost ($3 to $15 per methylphenidate pill in some areas) that makes it unethical? Or is it because use confers an unfair disadvantage on those who did not use a stimulant and are graded on the same curve as users? Practice is not necessarily just when one patient's competitive enhancements push other children further below the mean. Cosmetic EnhancementsHow much enhancement of normal variations in physical appearance is ethically appropriate? What about orthodontic appliances (braces) in situations that do not influence chewing or dental health? How much variation in tooth spacing is acceptable? If correction of imperfect dental appearance is good and ethically appropriate for affluent and insured children, should it be available to all children? Does a society's choice to allow “better smiles” for only some children make untreated children fall farther below the “normal” range and further compromise their potential for success in life?Similar questions can be applied to mole removal, laser treatment of hemangiomas, treatment of persistent male gynecomastia, body-piercing, and tattooing. Risks and benefits include psychological factors, as well as physical considerations. At what age should a child have independent decision-making responsibility to choose procedures that alter or manipulate physical appearance? When are physical stigmata of a disease or injury or physiological process “deformities” to be considered as medical conditions and when are they not? The ethical principle of dignity holds that we should appropriately regard our patients. Our treatment might not be ethically appropriate if it depends upon a notion that physical appearance is a major determinant of a child's worth. How much enhancement of normal variations in physical appearance is ethically appropriate? What about orthodontic appliances (braces) in situations that do not influence chewing or dental health? How much variation in tooth spacing is acceptable? If correction of imperfect dental appearance is good and ethically appropriate for affluent and insured children, should it be available to all children? Does a society's choice to allow “better smiles” for only some children make untreated children fall farther below the “normal” range and further compromise their potential for success in life? Similar questions can be applied to mole removal, laser treatment of hemangiomas, treatment of persistent male gynecomastia, body-piercing, and tattooing. Risks and benefits include psychological factors, as well as physical considerations. At what age should a child have independent decision-making responsibility to choose procedures that alter or manipulate physical appearance? When are physical stigmata of a disease or injury or physiological process “deformities” to be considered as medical conditions and when are they not? The ethical principle of dignity holds that we should appropriately regard our patients. Our treatment might not be ethically appropriate if it depends upon a notion that physical appearance is a major determinant of a child's worth. DiscussionClearly, ethical concerns can be raised about much of what occurs in everyday pediatric practice. The well-recognized principles of beneficence, nonmaleficence, justice, autonomy, and dignity apply but create tension. Attention to several themes can frame our thoughts as we navigate amidst ethical issues in our everyday practices:(1) Ethical issues are important to common aspects of pediatric practice. Identifying and recognizing these issues, we should acknowledge that our actions are influenced by our underlying beliefs. Do we view our professional role as treating illness and restoring health (as in the traditional view of “medical care”)? Or, do we see our role as enhancing the health of individuals so they can advance beyond their current normative level? (2) Biotechnology will permit advances and opportunities that may not be appropriate, affordable, or evidence-based. We should acknowledge that many practices are currently unproven and that we and our patients' families may have different views of the acceptability of various risks (maleficence) and benefits (beneficence) associated with unproven interventions. (3) Normal distributions reflect variations of normality. Not all children will be, could be, or should be above average. We should recognize that each time we attempt to enhance 1 patient, we leave untreated patients at a relative disadvantage. In addition, advocating for expensive enhancements in appearance could be interpreted as subtly implying that a child's emerging dignity depends more on appearance than on character. (4) Not all issues regarding one's physical or mental comfort are necessarily medical issues. Life includes struggles, and some struggles serve as the substrate for character development. As care providers, we should decide how much to emphasize avoidance of difficulty and how much to foster positive personal development of dignity through adversity. (5) All medical interventions carry potential for expense, adverse consequences, and failure, and we must recognize that benefits, costs, and risks of interventions might be differentially applied to children, as compared with their parents. (6) Parental desires are malleable by education, and pediatricians may be in an optimal position to teach. Perhaps we can even help shape society. Does our introductory small talk during office visits focus on appearance and achievement? We might better instead focus on well-being and adjustment.As pediatricians, we deal daily with our world's next generation. We must remain mindful of the ethical implications of our professional behavior. We should consider how we make “medical” cost-benefit decisions regarding elective and cosmetic enhancement interventions. We should seek to consider secondary effects on nontreated patients who will be relatively more disadvantaged by not being included among the treated few. As biotechnology advances and as social pressures evolve, we should thoughtfully strive to ensure that our patients are receiving truly ethical care.References available atwww.jpeds.com. Clearly, ethical concerns can be raised about much of what occurs in everyday pediatric practice. The well-recognized principles of beneficence, nonmaleficence, justice, autonomy, and dignity apply but create tension. Attention to several themes can frame our thoughts as we navigate amidst ethical issues in our everyday practices: (1) Ethical issues are important to common aspects of pediatric practice. Identifying and recognizing these issues, we should acknowledge that our actions are influenced by our underlying beliefs. Do we view our professional role as treating illness and restoring health (as in the traditional view of “medical care”)? Or, do we see our role as enhancing the health of individuals so they can advance beyond their current normative level? (2) Biotechnology will permit advances and opportunities that may not be appropriate, affordable, or evidence-based. We should acknowledge that many practices are currently unproven and that we and our patients' families may have different views of the acceptability of various risks (maleficence) and benefits (beneficence) associated with unproven interventions. (3) Normal distributions reflect variations of normality. Not all children will be, could be, or should be above average. We should recognize that each time we attempt to enhance 1 patient, we leave untreated patients at a relative disadvantage. In addition, advocating for expensive enhancements in appearance could be interpreted as subtly implying that a child's emerging dignity depends more on appearance than on character. (4) Not all issues regarding one's physical or mental comfort are necessarily medical issues. Life includes struggles, and some struggles serve as the substrate for character development. As care providers, we should decide how much to emphasize avoidance of difficulty and how much to foster positive personal development of dignity through adversity. (5) All medical interventions carry potential for expense, adverse consequences, and failure, and we must recognize that benefits, costs, and risks of interventions might be differentially applied to children, as compared with their parents. (6) Parental desires are malleable by education, and pediatricians may be in an optimal position to teach. Perhaps we can even help shape society. Does our introductory small talk during office visits focus on appearance and achievement? We might better instead focus on well-being and adjustment. As pediatricians, we deal daily with our world's next generation. We must remain mindful of the ethical implications of our professional behavior. We should consider how we make “medical” cost-benefit decisions regarding elective and cosmetic enhancement interventions. We should seek to consider secondary effects on nontreated patients who will be relatively more disadvantaged by not being included among the treated few. As biotechnology advances and as social pressures evolve, we should thoughtfully strive to ensure that our patients are receiving truly ethical care. References available atwww.jpeds.com.