Pediatric Residents Benefit from Case-Based Ethics Discussions
April 1, 2025
By Stacey Kusterbeck
Pediatric residents face many unique ethical issues, but often have no outlet to discuss these concerns. “Unique ethical concerns are mainly due to the nature of the surrogate decision-making model. Additionally, any social inequities affecting parents affect the medical decision-making for children,” says Zeynep N. Salih, MD, a neonatologist and ethicist at Indiana University School of Medicine. Residents see how social determinants of health can affect the quality of care, such as some families being unable to afford resources such as home ventilator therapy.
Residents also express ethical concerns about fragmented care, with clinical teams unable to get to know their patients and their goals and wishes. “Residents are the group who usually spend most of the time with the patients, parents, and other staff, including nurses. However, they are not the decision-makers,” notes Salih. Residents may disagree with decisions they think are not in the patient’s best interest, resulting in moral distress. “If that moral distress is not addressed appropriately, it may cause burnout. This is detrimental to physician well-being and, eventually, patient care,” says Salih.
At the beginning of the ethics elective in the pediatric residency program, Salih asks residents to describe a case where they wondered, “Is this the right thing to do?” Salih then identifies the ethical issues involved in the case and the gaps in the resident’s knowledge on how to respond to those ethical issues. The resident does a literature search and writes an ethical analysis about the case. This gives residents the opportunity to discuss their ethical concerns as a group.
One resident found the case-based ethics discussions very helpful in alleviating moral distress and decided to organize ongoing case discussions with fellow residents. As an ethics mentor, Salih helped the residents to create a case facilitation guide to use when presenting cases.
“Ethics learning in resident training programs is generally left to the hidden curriculum, where residents develop an understanding of the ‘right’ thing to do by watching attendings or peers,” observes Salih. Formal ethics curriculums usually include lectures on topics determined by the teaching faculty. “Thus, it is a top-to-bottom approach, with faculty becoming the teachers and role models for residents,” says Salih. Salih and colleagues conducted a study on the effect of the resident-led case-based ethics discussions.1 The researchers analyzed the effect of five one-hour sessions over a five-month period. During each session, a resident presents a case developed with the guidance of an ethicist. Pediatric specialists and other clinical areas (such as social work or nursing), join the sessions, offering perspectives residents do not usually have access to. The group then discusses the ethical issues involved in the case.
Resident attendees were surveyed before and after the intervention. Participants reported less moral distress and felt better prepared to address ethical issues after the program. The program has since expanded, with two residents volunteering to lead the case discussion series, working with chief residents to schedule the sessions.
“Residents should own their ethics learning. The ‘bottom-up’ approach — with residents taking ownership of the case discussions — works,” concludes Salih.
Reference
1. Lyle ANJ, Quain A, Ali S, Inanc Salih ZN. Decreasing perceived moral distress in pediatrics residents: A pilot study. Camb Q Healthc Ethics. 2024; Nov 20. doi: 10.1017/S0963180124000355. [Online ahead of print].
Pediatric residents face many unique ethical issues, but often have no outlet to discuss these concerns.
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