Jeremy Garrett

Bioethical decision‐making in pediatrics diverges from similar decisions in other medical domains because the young child is not an autonomous decision‐maker, while the teen is developing—and should be encouraged to develop—autonomy and decisional capacity. Thus the balance between autonomy and beneficence is fundamentally different in pediatrics than in adult medicine. While ethical dilemmas that reflect these fundamental issues are common, many pediatric physician and nursing training programs do not delve into the issues or offer specific training about how to deal with borderline cases.To meet this need, the Children's Mercy Bioethics Center in Kansas City, Missouri, created a program specifically dedicated to serving practicing, experienced pediatric health professionals. Our students come from various professional disciplines: they are doctors, nurses, social workers, chaplains, lawyers, psychologists, counselors, and hospital administrators practicing in pediatrics.

Many bioethicists view the primary task of bioethics as ‘value clarification’. In this article, I argue that the field must embrace two more ambitious agendas that go beyond mere clarification. The first agenda, critique, involves unmasking, interrogating, and challenging the presuppositions that underlie bioethical discourse. These largely unarticulated premises establish the boundaries within which problems can be conceptualized and solutions can be imagined. The function of critique, then, is not merely to clarify these premises but to challenge them and the boundaries they define. The second agenda, integration, involves honoring and unifying what is right in competing values. Integration is the morally ideal response to value conflict, offering the potential for transcending win/lose outcomes. The function of integration, then, is to envision actions or policies that not only resolve conflicts, but that do so by jointly realizing many genuine values in deep and compelling ways. My argument proceeds in stages. After critically examining the role and dominant status of value clarification in bioethical discourse, I describe the nature and value of the two agendas, identify concrete examples of where each has been and could be successful, and explain why a critical integrative bioethics – one that appreciates the joint necessity and symbiotic potential of the two agendas – is crucial to the future of the field. The ultimate goal of all of this is to offer a more compelling vision for how bioethics might conduct itself within the larger intellectual and social world it seeks to understand and serve

In this issue of the Report, Daniel Groll suggests new ways to understand old tensions between autonomy and paternalism. He categorizes disagreements between doctors and patients in four ways. Some are about the ends or goals of medical treatment. For these, he claims, patient choices are based upon patient values, and physicians should neither challenge nor assess them. More common are disagreements about the appropriate means to achieve an agreed-upon goal. These subdivide into two distinct categories—those in which the relative efficacy of possible means is “medically assessable” and those in which it is not. When disagreements are medically assessable, Groll argues, doctors can legitimately challenge patient ..