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

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 patient actually 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 Received for publication Aug 5, 1998; accepted Aug 21, 1998. Address correspondence to Robert D. Truog, MD, MICU, Children’s Hospital FA-108, Boston, MA 02115. PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Academy of Pediatrics.