In this paper, we examine the limits of informed consent with particular focus on ways in which various factors can overwhelm decision-making capacity. We introduce overwhelm as a phenomenon commonly experienced by patients in clinical settings and distinguish between emotional overwhelm and informational overload. We argue that in these situations, a clinician's primary duty is prevention of harm and suggest ways in which clinicians can discharge this obligation. To illustrate our argument, we consider the clinical application of genetic sequencing testing, which involves scientific and technical information that can compromise the understanding and decisional capacity of most patients. Finally, we consider and rebut objections that this could lead to paternalism.

Decisions related to births in the "gray zone" of periviability are particularly challenging. Despite published management guidelines, clinicians and families struggle to negotiate care management plans. Stakeholders must reconcile conflicting values in the context of evolving circumstances with a high degree of uncertainty within a short time period. Even skilled clinicians may struggle to guide the patient in making value-laden decisions without imposing their own values. Exploring the experiences of one pregnant woman and her caregivers, this case study highlights how bias may undermine caregivers' ability to meet their obligation to enhance patient autonomy and the moral distress they may experience when a patient's values do not align with their own. Management strategies to mitigate the potential impact of bias and related moral distress are identified. The authors then describe one management strategy used in this case, facilitated ethics consultation, which is focused on thoughtful consideration of the patient's perspective.

To date only a very narrow window of ethical dilemmas in psychogenic non-epileptic seizures (PNES) have been explored. Numerous distinct ethical dilemmas arise in diagnosing and treating pediatric and adolescent patients with PNES. Important ethical values at stake include trust, transparency, confidentiality, professionalism, autonomy of all stakeholders and justice. In order to further elucidate the ethical challenges in caring for this population, an ethical analysis of the special challenges faced in four specific domains is undertaken: (1) conducting and communicating a diagnosis of PNES; (2) advising patients about full transparency and disclosure to community including patients’ peers; (3) responding to requests to continue anti-epileptic drugs; and (4) managing challenges arising from school policy and procedure. An analysis of these ethical issues is essential for the advancement of best care practices that promote the overall well-being of patients and their families.

Dr. Marion's heart broke as she looked at the adorable 9-year-old girl who asked the question. Jill had been diagnosed with acute lymphocytic leukemia almost 5 months earlier, and Dr. Marion had quickly grown attached to the young girl. When Dr. Marion first started caring for Jill, it appeared that she was responding to treatment quite well. But over the past several weeks, Jill was in the hospital more often-the combined result of frequent infection and the toxic agents needed to treat her leukemia. Throughout Jill's treatment course, her parents had insisted she not be told about her diagnosis. A friend at school had died from cancer, and the loss had affected Jill profoundly. For months afterward, Jill had not wanted to go back to school and refused to sleep in her own room, preferring to be close to her parents. Not long after Jill seemed to be recovering from the most intense effects of her schoolmate's death, she was diagnosed with leukemia. Her parents feared that telling her she had leukemia would compromise her emotional health and well-being. They asked Dr. Marion and others involved in Jill's care to refrain from disclosing her diagnosis to her.Dr. Marion-and the rest of the medical staff-had thus far respected their wish, but felt strongly that Jill was mature enough to understand her condition and that she deserved to know what was going on, given that her leukemia might be life-limiting. Once, when her parents were not around, Jill asked what was wrong with her, and Dr. Marion offered an explanation that did not mention cancer but focused on side effects of medications. Now, Jill was asking again. CommentaryJill's parents are not alone. Families are generally concerned that knowledge of a life-threatening diagnosis will harm the patient's psychological and physiological well-being [1][2][3][4][5]. In the past, physicians routinely withheld medical information from a patient if they believed the information would harm the patient's overall health, justified by what is known as "therapeutic privilege" [1-3, 6, 7]. While not exclusive to pediatrics, the ethical dilemmas raised by nondisclosure requests are complicated further when made by a parent of a minor patient [8][9][10][11]. Dr. Marion and her team must grapple with reconciling their obligations to Jill with Jill's parents' authority to make decisions on behalf of their 9-year-old child [10].

No abstract