Pediatricians must address adverse outcomes with compassion, resolve

Despite best efforts to do no harm, clinicians should be prepared to respond to patients who experience adverse outcomes even if everything is done right. Often thought to refer only to medical error, the term “iatrogenesis” characterizes a wider range of possible health care outcomes that are, as the Greek etymology suggests, physician-generated. Iatrogenic outcomes are particularly fraught in pediatrics, due to children’s inherent vulnerability as patients who typically lack decision-making authority.

This month’s issue of the AMA Journal of Ethics® grapples with neglected clinical and ethical questions about pediatric iatrogenesis, including how clinicians communicate iatrogenic risks to patients’ parents or guardians, how clinicians manage therapies with inevitable iatrogenic harms, as well as how clinicians might consider, respond to, and mitigate iatrogenic consequences of their practices.

Take a moment to consider this question: A 12-year-old girl identifies as a boy, has been diagnosed with gender dysphoria (GD), and wants to begin gender transitioning with prepuberty hormone therapy. Her physician worries about the long-term iatrogenic risks of therapy. How should the physician respond?

• Explain iatrogenic consequences of prepuberty hormone therapy, noting that GD does not always persist into adolescence.
• Require this patient to undergo mental-health evaluation. Begin only reversible treatment to suppress puberty.
• Begin only reversible treatment to suppress puberty.

Give your answer and find responses to this question in the August issue of the AMA Journal of Ethics, which features numerous perspectives on ethical questions related to pediatric iatrogenesis.

Articles include:

“Should Clinicians Medicate Against Structural Violence? Potential Iatrogenic Risks and the Need for Social Interventions.” Physicians should weigh not only the iatrogenic risks of off-label antipsychotic medications but also the possible consequences of failing to treat related, complicating social factors. Advocates must address structural violence and failures of imagination in their efforts to improve mental-health equity among vulnerable youth.

“How Should Physicians Help Gender-Transitioning Adolescents Consider Potential Iatrogenic Harms of Hormone Therapy?” Counseling and treatment of transgender youth can be challenging for mental-health practitioners, as increased availability of gender-affirming treatments in recent years raises ethical and clinical questions. In cases involving adolescents, it is critical that clinicians communicate appropriate expectations about the effectiveness and limitations of hormone therapy, as well as the risks of psychological and physical iatrogenic effects.

“Are Physicians Blameworthy for Iatrogenic Harm Resulting from Unnecessary Genital Surgeries?” Physicians should, in certain cases, be held accountable by patients and their families for harm caused by “successful” genital surgeries performed for social and aesthetic reasons. It is important for physicians not just to know when and why to perform genital surgery, but also to understand how their patients might react to wrongful performance of these procedures, and to respond to their own blameworthiness in socially productive and morally restorative ways. 

“Clowning as a Complementary Approach for Reducing Iatrogenic Effects in Pediatrics.” Hospitalized children who undergo painful procedures are more susceptible than others to experiencing iatrogenic effects, such as anxiety, pain and stress. Clowns in the clinical setting have been found to be effective in reducing children’s experiences of these effects during hospitalization and before procedures.

“The AMA Code of Medical Ethics’ Opinions Related to Iatrogenesis in Pediatrics.” Although any patient can experience an iatrogenic outcome, pediatric patients are the most vulnerable to life-threatening complications. The AMA Code of Medical Ethics does not have any opinions that address iatrogenesis in pediatrics specifically, but it does offer guidance on pediatric decision making, preventing error and harm, and disclosing errors.

In the journal’s August podcast, Robert Nelson, MD, PhD, MDiv, a senior pediatric ethicist with the Food and Drug Administration, discusses strategies for communicating about iatrogenic outcomes with the parents and guardians of pediatric patients. Later in the episode, Gigi McMillan, the mother of a pediatric brain-tumor survivor, discusses how networks of peer mentors can help families navigate these painful situations.

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The journal is accepting applications from medical students, residents and fellows (MDs or DOs) in U.S.-based programs to serve as theme issue editors for monthly issues to be published from November 2018 through October 2019. Learn more.

Upcoming issues of the AMA Journal of Ethics will focus on incarceration and correctional health care as well as clean-water access and the roles of clinicians. Sign up to receive email alerts when new issues are published.

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