Jeremy Garrett, PhD (Host): Hello, and welcome to another edition of the Pediatric Ethics Podcast, sponsored by the Children's Mercy Bioethics Center. My name is Jeremy Garrett and I'll be your host. Today, we'll be discussing the concept of a child's relational potential and the role that this concept might play in certain pediatric cases. And I'm thrilled to be joined today by Dr. Ian Wolfe, who is the senior clinical ethicist at Children's Minnesota and handles lots of ethics consults in which this concept can arise. Ian, would you mind starting off by telling us a little bit more about what is even meant by this idea of a child's relational potential?

Ian Wolfe, PhD: Sure. Thanks for having me. So, relational potential came up initially as a term to try to address some of the inadequacies of what we consider the best interest standard, particularly when it came to children who had unfortunately suffered such severe neurologic damage that it was much harder to really assess their benefits and burdens. So, the relational potential looked at their ability to be in relationships in the future, their potential to have relational ability to interact with their surroundings, to have self-consciousness, to know others around them, et cetera.

Host: Right. So, right off the bat, then we are distinguishing relational potential from any of the other commonly cited pediatric bioethics standards or principles, like the best interest standard or the harm principle. And this idea of relational potential then is a kind of limited tool that only applies in a certain subset of really ethically challenging pediatric cases if I'm hearing you right.

Ian Wolfe, PhD: Correct. Or it has more ethical salience in certain different cases, or it becomes a consideration in only a small subset of cases.

Host: Right. So, it's not as if this arises in every case and we consider a particular child's relational potential and that affects the decisions that are made with them. This is really only something that applies in a small subset of really challenging cases where the ability to assess a child's condition and ability to be benefited or burdened by treatment is really a question.

Ian Wolfe, PhD: Yeah. So, these are children, and early writers have written about this, where it becomes really hard to even assess whether they can perceive benefits or burdens, you know.

Host: Right. Whether they have interests in the first place.

Ian Wolfe, PhD: Correct. And so, this comes about in a way to try to provide us with some ethical considerations for pursuing further interventions or not, or figuring out what are appropriate things ethically to do for a child in this situation?

Host: Well, with that in mind, can you tell us just a little bit more about how this concept has been used in pediatric ethics, in the literature and how people have tried to use it to settle or make recommendations in the kinds of cases that in which it can arise?

Ian Wolfe, PhD: Yeah. I mean, the first formulation was back in 1984 by John Arras, who formed the idea of the relational potential based on the lack of the applicability of the best interest standard towards these children, where the balance of burdens and benefits are impossible to discern, meaning they can neither experience pleasure nor pain. And he sets out this standard as a morally relevant distinction where it doesn't necessarily deny that families might derive satisfaction in caring for a child in this particular situation, and a desire to keep them alive. But that these particular reasons have nothing to do with the child's best interests, right? He argued that we cannot attribute a best interest focus towards sustainment of these children's lives, and thus there's no ethical obligation to prolong their lives by medical treatments. And he set these out as morally significant psychological properties as a capacity for self-consciousness and the ability to relate to other people and acknowledging the significant issues of prognostic uncertainty with that.

Host: So, that sounds prima facia reasonable position to take. Where have others disagreed with Arras?

Ian Wolfe, PhD: So, there's been some disagreement most recently. And Whiteman, et al, in Hastings Forum have put out that they believe through a care ethics method that even one-sided relationships can derive value. So, the relational potential is used from their standpoint in a different way to provide ethical consideration to the value that a family gets, even if a one-sided relationship, so the child can't reciprocate that relationship objectively. They find that this becomes through care ethics lens an ethically important consideration in that regard.

Host: Right. And I know you've been working on this concept yourself. Where do you find yourself coming in into that debate? And at what points do you want to agree and disagree with those positions?

Ian Wolfe, PhD: I actually agree with all of their positions. I do think it's an important distinction or consideration to make for that families can view that one-sided relationship as valuable. But I actually agree with Dominic Wilkinson and the author, co-authors came out later with, is talking about reviewing the standard more as a threshold, meaning there's a specific threshold where those capacities, you either are below the threshold or above the threshold. And then, I would tie a little bit of what actually Arras was saying in the beginning, is that it's not that this is the only consideration that bears out over weight, but what it does is if somebody's below a threshold of relational potential, I would say that then they lack the ability to appreciate the benefit of those treatments, and therefore the ends of medicine may not be met, and therefore there is no obligation for clinicians to engage in medical interventions that might sustain that life. It doesn't necessarily mean that they can't.

Host: Right. So, we've kind of been looking at this in the level of a little bit more abstract philosophical conceptual analysis. I'm wondering if you could kind of make this a little more concrete by describing a case in which this concept might arise and using that case to highlight how you are thinking about the concept of relational potential over and against these other folks who have written about it.

Ian Wolfe, PhD: So, I could take an amalgamated case here, which is a pretty common, unfortunately, one in many pediatric ICUs where you have Sarah is a five-month-old female brought into the ED by emergency medical services with cardiac arrest after a co-sleeping suffocation event. There was an estimated significant time without oxygen prior to initial CPR and return of spontaneous circulation, which was achieved an hour later. So following standard treatment for targetted temperature management, Sarah's status is evaluated. She initiates some disorganized breaths, but her brain stem reflexes are overall absent. She shows decorticate posturing and has episodes of dysautonomic storming. Cerebral angiogram is done. It shows no blood flow to the three of the four arteries supplying blood to the brain, but minimal flow in the fourth, thus ruling out brain death. Tracheal extubation is attempted, which failed almost immediately. And with no sedation, she only shows response through grimacing and posturing during her episodes of storming. The medical team recommends compassionate extubation. The parents refuse. Conversations continue. Sarah continues in the same, if not worse condition, and the parents request a tracheostomy for chronic ventilation and the team declines. In this scenario here, we have what I would say sufficient certainty and that's important to prognosticate that this child will never regain the ability to appreciate the benefits of this treatment. And therefore, any benefits of medical interventions are not appreciated by the patient and therefore would be for the benefit of other stakeholders.

Host: So, how do you evaluate that ethically using your position in this debate?

Ian Wolfe, PhD: It is an important distinction here to point out. It's not saying that parents can't find value from this and surely want to care for this child. It really comes down to an obligation issue of whether clinicians are obligated to offer this. And from an ethical perspective, if the patient themselves with sufficient certainty, mind you, will not appreciate the benefits of a medical treatment, then there becomes a point at which there's no obligation then for a clinician to engage in those medical treatments. Because for the ends of medicine to be met, the patient must in some way appreciate those benefits, relative to age-appropriateness and developmental level.

Host: You've mentioned the idea of the ends of medicine a couple of times now. I'm wondering if you could say a little bit more about that, and what you take to constitute the ends of medicine. Since it does seem to be playing an important role here, there's obviously a history with that term. Going back to a famous article by Leon Kass, which fairly narrowly defined the ends of medicine, such that many things that we do today would not actually count as following within that scope. I'm wondering how you're using that concept here. How broad or narrow are the ends of medicine and what is it about what's happening in this case that falls outside of it?

Ian Wolfe, PhD: Right. Good question. And just a full disclosure, my ethics committee, which that's where I get a lot of the moral discussion from how I then practice ethics, really relies a lot on the SCCM 2016 statement, A. Kon, et al, looking at the idea of potentially inappropriate, non-beneficial or harmful. So, that's where we get this one idea that, you know, appreciating the benefits of a treatment. And the ends of medicine, very simply from my perspective, is that there must be some patient benefit to that that's not merely adequate biological survival, right? So, the patient must appreciate that benefit. Now, there could be a point where there's a child who we have uncertainty but could potentially very lowly appreciate or reciprocate relationship such as they might be able to track their parent across the room. They might be able to smile at their touch. Those are all things to me that are reciprocating of a relationship, right? An infant, a newborn can reciprocate a relationship in their developmental and age-appropriate ability. Therefore, there's a perceivable benefit there. And as another person pointed out, say a 10-year-old who becomes locked in still has the capacity to reciprocate a relationship even though they lack then now the physical ability to do so.

Host: So, a final question that I think many of our listeners would have at this point is how we go about determining a child's relational potential and whether or not there's an objective way to do that, or whether it's always inherently subjective and thus subject to significant disagreement between parents or other stakeholders and members of the clinical team or the administration of a hospital or clinic. Can you say a little bit more about how you think about that question of determining a child's relational potential when there's potential for such disagreement and subjective assessments of that?

Ian Wolfe, PhD: Yeah. And, you know, this is something that commonly comes up in many ICUs. And I want to set aside the idea that we're not debating personhood here, and that comes up in a little bit of the discourse around this topic. You know, because what I'm not talking about is determining, you know, when somebody is a person or not. We're determining the threshold for which there's a potential to reciprocate relationships. And that's a high degree of certainty. And I think this is something within the ICUs that we're used to, at least ethicists, engaging as prognostic uncertainty increases, so should the zone of parental discretion.

And so, what we're really talking about is a very small amount of patients who, for lack of sort of better descriptives, are either indicated to be brain dead or near brain dead, right? So, those are the cases where we more often have that sufficient certainty, right? We can never be absolutely certain, but we have sufficient certainty. And so, this is something you very rarely see often in the neonatal population except for certain cases and a few diagnoses. Then if there's disagreement, this follows your normal dispute resolution process that many pediatric hospitals have, which often is based around those multi-societal statements around potentially inappropriate, non-beneficial treatment or the SCCM 2016 statement, which details out a sort of dispute resolution process. And then of course, looking for which part of that process is ethics consults, second opinions, et cetera. And so, you usually have the team that has consensus before you go into this process. You know, if the team disagrees, well, when reasonable people disagree, parents are empowered to then make that decision. But if the team has consensus that this is something they're going to offer, then looking for an institution that might, or if the institutions that you look for second opinions also agree, then you are building more consensus that this isn't the appropriate treatments to pursue in this case.

Host: I want to thank Dr. Ian Wolfe for joining us today to discuss this concept of a child's relational potential. This has been another episode of the Pediatric Ethics Podcast, sponsored by the Children's Mercy Bioethics Center. Thank you.