Is it okay to answer, "What would you do if this were your child?"

Not surprisingly, the significance of the question increases proportionally with the seriousness and urgency of the issue. But even if the problem is quite minor, it's worthwhile to examine from an ethics perspective what professionals are doing when they give or don't give their personal opinion.

In 1989, William Ruddick, director of the Bioethics Centre at New York University and a philosopher and adjunct professor in psychiatry, was the first academic-clinician to tackle this issue in the ethics literature. A decade later, Robert Truog, a pediatric critical care specialist, anesthesiologist and medical ethicist at Harvard Medical School, offered his advice. Both men concluded that a doctor or nurse should not tell a child's parents what he or she would do "if your child were mine."

They offered five reasons. First, the parent may inappropriately assume that the practitioner is as good a parent as he or she is. Second, the parent may incorrectly assume shared he or she has the same values and parenting experiences as the practitioner. Third, the decision about a particular treatment or therapy could mean a paternalistic shift from parent to professional. Paternalism in this kind of situation is unacceptable because there is an able and caring, albeit worried, parent at hand. Fourth, professional optimism is common. This means that expected benefits and risks of medical treatments tend to be rated more positively by health care providers than by the average person. Finally, other family members or close friends likely are better able to help a parent evaluate treatment options because they know more about the child's life and the parent's parenting priorities or "style" than does the practitioner.

A few years have passed since Ruddick and Truog presented their arguments. Other members of the health care ethics community have weighed in. This time, they argue in favour of professionals telling parents what they would do, based on four reasons: First, the very fact that parents ask means they trust the professional a great deal. Second, answering the question constitutes an opportunity for even deeper conversations between parents and professional. Third, some of the responsibility should shift to the practitioner. And fourth, providing their own perspective may help reduce some of the practitioner's guilt if the outcomes are less than hoped for.

What can I contribute to this debate? Two things. It's useful, I think, to first consider how the parents' question can have different meanings. A parent may be trying to figure out whether the professional is withholding information about certain treatment options in an effort to not increase the complexity or burdens of the decision. On the other hand, a parent may be questioning the nature of their relationship with their child; for example, "Am I putting my own interests first?" In a similar vein, parents may wonder, "Are we expecting our child to endure too many burdens and tolerate too much risk? Burdens and risks that outsiders would consider excessive or even heartless?" Parents might feel that they still don't understand the situation or the options adequately and therefore wish to tap into the deeper clinical knowledge of the professional. The different reasons for asking means that professionals should try to ascertain what parents are really asking when they say to you, "What would you do if this were your child?"

As for myself, I agree that practitioners should not directly answer the question. Instead, they should re-focus on "these parents and their child." For example, saying something like "Based on my conversations with you, it seems that x, y and z have been critical in past decisions you've made about your child's illness as well as about your family as a whole. Do you think x, y and z apply to the decision you're dealing with right now? Or is this situation so different that x, y and z don't fit?" Such remarks confirm that the professional has indeed paid close attention to what the parent has already said and done. The remarks also encourage careful consideration of the parent's and family unit's values, priorities and realities. Moreover, the professional also remains available to the parents and committed to the child's well-being, without accepting or lapsing inappropriately into the role of "this child's parent."

Note: I've deliberately used both the singular and plural form of "parent" to affirm that children can have one or more parent. As captured in past, often heated, debates about the ethics of various reproductive technologies, parenthood--and the responsibilities and rights associated with it--can be based on providing needed gametes, gestation and birthing or social rearing.

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Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.

Do you have an ethics question for Dr. Russell? Submit questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.