Determination of Attitudes and Knowledge Levels of Pediatricians About Pediatric Medicolegal Problems in Turkey

doi:10.21203/rs.3.rs-2700742/v1

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Research Article

Determination of Attitudes and Knowledge Levels of Pediatricians About Pediatric Medicolegal Problems in Turkey

https://doi.org/10.21203/rs.3.rs-2700742/v1

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Introduction

In recent years, there has been an increase in allegations of medical errors, particularly related to issues of consent. The role of legal representatives in making decisions about children's medical treatment has resulted in various legal and ethical dilemmas. This study aimed to assess the knowledge and awareness of pediatricians on medicolegal issues.

Methods

The study was conducted prospectively and cross-sectionally. Participants were presented with 14 case examples and were asked 25 questions about their knowledge of the necessary information, consent, documents, and procedures required in each case. They were asked to score their adequacy on a scale of 1 to 5 points. Mann Whitney U and Kruskal Wallis tests were used statistically.

Results

A total of 209 pediatricians participated in the study, 66% of which are working in tertiary care hospitals. The results indicated pediatricians were unsure about their knowledge of necessary information, consent, documents, and procedures for children, with an average score of 3.19 out of 5. They also felt inadequate when faced with treatment refusal, with an average score of 2.77 out of 5. No significant differences were found in the results based on professional seniority or job title. Furthermore, only 2% of the pediatricians believed that children under 12 years old could understand their medical treatment options.

Conclusion

The study highlights that pediatricians need more knowledge on basic legal issues related to information, consent, and refusal of treatment. Legal education should be included in medical schools' curricula to prevent lawsuits and improve patient care, and pediatricians should receive legal training to enhance their knowledge of medicolegal issues.

Consent Forms

Informed Consent

Pediatrician

Children

Malpractice

Medical law

Curriculum

Medical malpractice is a serious public health problem. Medical malpractice incidents are rising in Turkey and worldwide and have become an important issue for developed and developing countries [1]. Depending on these claims, there is a 70–80 times increase in compensation burden in five years from 2016 to 2020. In addition, among the 5,933 medical malpractice lawsuits filed against the Ministry of Health in the last ten years until 2022, pediatrics departments rank first among internal branches (excluding emergencies) [2]. For medical practices to be considered lawful, primarily, the consent of the person concerned is needed, authorized persons by medical standards must perform the medical procedure, and there must be a reasonable indication [3]. While medical standards and issues are generally evaluated by experts, such as information and consent, medical records and documents are legal issues that the judge can directly assess, with predominant judicial and legal aspects [4].

Since the basic principle to be followed in medical practices is the person's autonomy [5], the main determinant for the legal acceptance of medical practices is the person's consent [6]. In addition, the validity of the consent depends on fulfilling the obligation to inform [7]. For this reason, medical practices infringing the obligation to inform and the consent of the person concerned are generally regarded as unlawful and considered medicolegal malpractices.

In general, there is no problem with the consent of fully qualified persons to medical practices directed toward them [8]. However, in medical practices for children, there are medical, legal, and ethical dilemmas when making decisions on behalf of the child [9]. Regardless if the discerning child can make their own decisions, the legal representative decides on behalf of the child.

However, this right of the legal representative to decide on behalf of the child is not absolute [10]; known judicial dilemmas date back to the 19th century. In the decision of the Supreme Court of the German Reich (Reichsgericht) in 1894, the gangrenous leg of a 7-year-old girl was amputated despite her father's opposition to surgery, and the amputating physician was held responsible for this intervention against her father's consent [11]. As a matter of fact, due to these dilemmas, the issue of consent to medical practice in children is specifically regulated by article 70 of the Law on the Practice of Medicine and Medical Arts," Law on the Practice of Medicine and Medical Sciences," dated 1928 and numbered 1219.

On the other hand, medical records and documents, considered within the scope of personal rights and medical practices, are important both in terms of the physician's duty of care and attention and the burden of proving consent, which is the physician's responsibility [12]. Also, violation of the duty of care and attention in medical records can be sued independently [13]. Since children have legal representatives who make decisions on their behalf, pediatricians are obliged to pay more attention to medical records belonging to children [14].

Pediatricians are in a sensitive position regarding the child's health for the best interests of children in need of legal protection. As mentioned above, consent, refusal of treatment, medical records, and other documents in children are subject to different rules and procedures compared to adults and may lead to various dilemmas. Due to these dilemmas, they must pay more attention and care, especially regarding consent and proof.

For these reasons, in our study, pediatricians were asked to evaluate themselves in medicolegal issues such as informing, consent, refusal of treatment, medical records, documents, and procedures in medical applications for children, which could be the subject of lawsuits with the claim of medical malpractice. It was intended to evaluate their attitudes and knowledge levels on these issues.

2.1. Study Design

Our study is prospective, survey-based, and cross-sectional. The study was conducted between 04.07.2022 and 03.08.2022 after obtaining local ethical approval. Ethical approval was obtained from Izmir Bozyaka Training and Research Hospital Ethics Committee for the study on 06.06.2022 with the number 2022/113. Informed consent was obtained from the participants.

First, the participants were asked about their demographic information, age, gender, institution, title, working years, legal problems, and whether they had received training.

In possible case examples, the answers were numbered from 1 to 5 on a Likert Scale; The pediatrician was asked to mark one if she/he felt very inadequate about the answer to the question and five if she/he felt completely adequate.

The 14 case scenarios are compiled from cases frequently encountered in pediatric medical practice and are subject to judgment.

2.2. Case Scenarios

The 14 case scenarios and questions are given in this section. The 11 questions are asked about the pediatrician's perception of his competence in diagnosing the patient, informing the patient about the treatment, and in cases where the patient refused the treatment [15–20].

Two questions were asked about pediatricians' thoughts about discernment and decision-making in children [14]. One question concerns the participant's compliance with the child's decision, depending on whether the family accepts it. Another question was about pediatricians' thoughts about discernment in children.

2.3. Data collection

Since no similar studies could be found in the literature, the questionnaire was sent to 50 pediatricians in the digital environment to determine the question's reliability. It was seen that the questions were statistically significant and were asked to the pediatricians who constituted the universe of the study. The universe of the study, The "Pediatrics Workshop" group, which has 2586 members throughout Turkey and continues its activities on social media, consists of pediatricians working in university and training research hospitals located in the province of Istanbul.

The questionnaire was prepared as digital forms and sent to the target volunteers in a digital environment. Participants were asked to answer the questions anonymously and within 30 minutes.

Inclusion criteria were set for all pediatricians (major/minör), residency students, specialists, and lecturers.

The questions were sent to 2673 pediatricians, totaling 209 answerings (12.7%). Since all participants answered the questions completely, no person was excluded from the study. Exclusion criteria were determined by not accepting to participate in the study and incomplete answers to the questions.

The participants were asked whether they had received any training on medical law, such as seminars or lectures, and whether they had ever experienced a situation brought to court due to a judicial medical practice [21].

2.4. Statistical Analysis

Cronbach's alpha was calculated as 0.976 because of the reliability analysis performed to measure the reliability of the questionnaire prepared to investigate pediatricians' awareness of legal issues. The preliminary Analysis with 50 pediatricians determined that the pediatricians understood the questions clearly. The study was completed with 209 pediatricians with a 5% margin of error and 95% confidence interval.

Statistical Package for Social Sciences (SPSS) 26.0 software program was used to analyze the data obtained from the physicians participating in the study. While evaluating the demographic data obtained from the physicians participating in the study, frequency and percentage were used among descriptive statistics. The Kolmogorov-Smirnov test was applied for the total scores of the questions in the scale. Nonparametric tests were applied for total scale scores that did not show normal distribution. Mann Whitney U and Kruskal Wallis test examined the relationship between physicians' descriptive characteristics and scale scores. Significant (p) values below 0.05 were considered statistically significant.

Two hundred-nine pediatricians and pediatric residents participated in the study. The 14 questions prepared were statistically analyzed with the gender, title, and institution of the physicians individually. However, all results found a p-value above 0.05 (the highest 0.108 and the lowest 0.908).

3.1. Demographic Information of Pediatricians

The mean age of participants was 39.06 ± 8.29; 68% were specialists and fellow minor pediatricians, and 66% worked in tertiary hospitals (Table 1).

Table 1

Demographic Information of Pediatricians
		n	%
Gender
	Female	124	59.3
	Male	85	40.7
Title
	Resident	35	16.7
	Specialist	108	51.7
	Subspecialist	34	16.3
	Academician	32	15.3
Working Experience
	< 5 years	28	13.4
	5–10 years	54	25.8
	10–20 years	71	34.0
	> 20 years	56	26.8
Institution
	Public Hospital	37	17.7
	University & Training Research Hospital	137	65.6
	Private Hospital & Officer	35	16.7

3.2. Case Scenarios

Twenty-five questions about 14 possible cases related to medical law information were directed to participating pediatricians in the research. According to these cases, feeling competent about the information, consent, documents, and correct procedures to be followed was evaluated between 1 and 5 points for each question and 25 and 125 points.

In this framework, it was determined that the answers were 74.25 ± 23.95 points, the general adequacy averages were 3.19, and the average proficiency in cases of refusing treatment in the same scenarios was 2.77 (Table 2).

Table 2

Adeqeuacy of Pediatricians in Possible cases with medicolegal issues (It was asked to Pediatrists whether they feel properly adequate about informal, consent, documents and methods to follow on possible cases with various issues)
Possible Case Example		1	2	3	4	5	Mean
1. High grade prematurity, 1090 gr. newborn with respiratory distress, to be discharged after a four weeks treatment period in intensive care unit (ICU).
a) While discharging*	n	27	26	67	60	29	3.18
a) While discharging*	%	12.9	12.4	32.1	28.7	13.9	3.18
b) When the family refuses the discharge*	n	40	43	64	49	13	2.77
b) When the family refuses the discharge*	%	19.1	20.6	30.6	23.4	6.2	2.77
2. A four-year-old girl presented with complaints of fever and respiratory distress. The pediatrician has diagnosed her with pneumonia and he/she thinks it is an indication for treatment in the ICU.
a) Regarding the child's admission to the ICU; *	n	18	27	49	77	38	3.43
a) Regarding the child's admission to the ICU; *	%	8.6	12.9	23.4	36.8	18.2	3.43
b) When the family refuses the admission to the ICU; *	n	33	46	65	45	20	2.87
b) When the family refuses the admission to the ICU; *	%	15.8	22.0	31.1	21.5	9.6	2.87
3. A three-year-old boy has moderate diarrhea. Although his general condition is not bad. the pediatrician thinks it would be best if he is followed in the service.
a)Regarding the child's admission to the ward *	n	16	17	54	84	38	3.53
a)Regarding the child's admission to the ward *	%	7.7	8.1	25.8	40.2	18.2	3.53
b) When the family refuses child’s admission to the ward *	n	27	30	73	58	21	3.08
b) When the family refuses child’s admission to the ward *	%	12.9	14.4	34.9	27.8	10.0	3.08
4. It is necessary for the sixty-day-old baby to be vaccinated within the framework of the Ministry of Health Vaccination Program of the Republic of Turkey.
a) Regarding childhood period vaccinations *	n	24	28	54	67	36	3.30
a) Regarding childhood period vaccinations *	%	11.5	13.4	25.8	32.1	17.2	3.30
b) When the family refuses the vaccination of the child *.	n	33	49	59	48	20	2.87
b) When the family refuses the vaccination of the child *.	%	15.8	23.4	28.2	23.0	9.6	2.87
5. It is necessary for the newborn to be screened for congenital hypothyroidism, phenylketonuria, biotinidase deficiency and cystic fibrosis within the scope of the Newborn Screening Program.
a)Regarding newborn screening tests *	n	26	31	45	70	37	3.29
a)Regarding newborn screening tests *	%	12.4	14.8	21.5	33.5	17.7	3.29
b)When the family refuses the newborn screening test *	n	35	53	66	37	18	2.76
b)When the family refuses the newborn screening test *	%	16.7	25.4	31.6	17.7	8.6	2.76
6.A twelve-year-old boy comes to the emergency room with abdominal pain and is diagnosed with acute appendicitis and requires urgent surgery.
a) Regarding pediatric emergency surgeries *	n	27	18	52	76	36	3.36
a) Regarding pediatric emergency surgeries *	%	12.9	8.6	24.9	36.4	17.2	3.36
b) When the family refuses the child's surgery *	n	38	45	65	42	19	2.80
b) When the family refuses the child's surgery *	%	18.2	21.5	31.1	20.1	9.1	2.80
7.The pediatrician considers it appropriate to administer an intramuscular injection to a six-year-old girl for non-emergency treatment.
a) Regarding the injection of the medication to the child *	n	20	38	48	77	26	3.24
a) Regarding the injection of the medication to the child *	%	9.6	18.2	23.0	36.8	12.4	3.24
b) When the family refuses the injection *	n	32	41	57	62	17	2.95
b) When the family refuses the injection *	%	15.3	19.6	27.3	29.7	8.1	2.95
8. A child under follow-up and treatment with the diagnosis of epilepsy comes to the emergency room in the evening with a convulsion and the pediatrician decides that an immediate administration of diazepam injection is needed.
a) Regarding the emergency injection to the child *;	n	28	30	49	72	30	3.22
a) Regarding the emergency injection to the child *;	%	13.4	14.4	23.4	34.4	14.4	3.22
b) When the family refuses the emergency injection *	n	41	44	61	43	20	2.79
b) When the family refuses the emergency injection *	%	19.6	21.1	29.2	20.6	9.6	2.79
9. A 15-year-old boy comes to the outpatient clinic alone with the complaints of fever and sore throat.
a) Concerning the child’s application to the polyclinic alone *	n	38	42	56	52	21	2.88
	%	18.2	20.1	26.8	24.9	10.0	2.88
b) When the child refuses examination and treatment *	n	54	50	51	42	12	2.56
b) When the child refuses examination and treatment *	%	25.8	23.9	24.4	20.1	5.7	2.56
10.A fourteen-year-old girl comes to the policlinic with her aunt (who is not the legal guardian) with complaints of fever and sore throat.
a) Concerning the child’s application to the polyclinic with a relative who is not a legal representative*	n	36	56	60	42	15	2.73
	%	17.2	26.8	28.7	20.1	7.2	2.73
b) When the child refuses treatment *	n	49	65	56	27	12	2.46
b) When the child refuses treatment *	%	23.4	31.1	26.8	12.9	5.7	2.46
11. A fifteen-year-old girl, who is hospitalized in the ward for treatment and follow-up. Should be given antibiotic treatment along with other treatments within the scope of her treatment.
a) Regarding the child's treatment *	n	31	45	53	54	26	2.99
a) Regarding the child's treatment *	%	14.8	21.5	25.4	25.8	12.4	2.99
b) When the child refuses antibiotic therapy *	n	46	50	62	36	15	2.64
b) When the child refuses antibiotic therapy *	%	22.0	23.9	29.7	17.2	7.2	2.64
12.A five-year-old boy was brought to the outpatient clinic by his mother with the complaints of cough and diarrhea. During the physical examination. the pediatrician saw a large number of various ecchymoses in the child's abdomen and back. When asked the mother said she had recently fallen off her bike. In the face of suspicion of physical and/or psychological abuse of the child *	n	32	48	68	44	17	2.84
	%	15.3	23.0	32.5	21.1	8.1	2.84
13.A four-year-old boy was brought to the outpatient clinic by his mother with complaints of bleeding from his anus, difficulty in pooping, and constipation. In the examination of the child. the pediatrician detected two very deep fissures. skin abrasions and ecchymotic lesions among the widespread macerated areas in the perianal region. In the face of suspicion of child sexual abuse *	n	40	59	51	41	18	2.70
	%	19.1	28.2	24.4	19.6	8.6	2.70
14.The mother of a 5-year-old girl with a life-threatening condition, whom the pediatrician followed in the service with the diagnosis of severe pneumonia. refuses the treatment on the 2nd day of the treatment and she is ready to sign the necessary form and leave the service with her child. She states that she bears all responsibility. even though the pediatrician states it's life-threatening. About the family signing the treatment refusal form *	n	33	39	62	51	24	2.97
	%	15.8	18.7	29.7	24.4	11.5	2.97
* I feel competent about the necessary information. consent. documents and procedures.

3.3. Physicians' Assessment of the Child's Decision

In Question 11(C), pediatricians are asked to evaluate the medical decision of the child, who is considered to have the power to discriminate, according to the family's situation. It is seen that 42% of the pediatricians will not comply with the decision of the child when they are not with the family, 47% of the pediatricians will not comply with the decision of rejection if the family accepts the treatment, and 48% of them are undecided against the decision of acceptance by the child when the family does not get the treatment (Table 3).

Table 3

Physicians' Assessment of the Child's Decision
		I obey the child's decision	I do not obey the child’s decision	I am undecided
Not with the Family	n	33	87	89
Not with the Family	%	15.8	41.6	42.6
The Family accepts	n	58	98	53
The Family accepts	%	27.8	46.9	25.4
The Family does not accept	n	33	76	100
The Family does not accept	%	15.8	36.4	47.8

3.4. Pediatricians' Thoughts About Discernment in Children

In Question 11(D), pediatricians were asked about their thoughts on children's discriminating power. It is seen that 66% of the pediatricians stated that children under the age of 12 could not discern, 61% of them stated that they should be evaluated on a case-by-case basis for children between the ages of 12–15, and 54% stated that there is a power of discrimination for those aged 15 and over (Table 4).

Table 4

Pediatricians' Thoughts about Discernment in Children
		Has the Power of Discernment	No Discernment	Must be Evaluated Case by Case
< 12 years	n	5	135	65
< 12 years	%	2.4	65.9	31.7
12–15 years	n	30	50	125
12–15 years	%	14.6	24.4	61.0
> 15 years	n	113	15	81
> 15 years	%	54.1	7.2	38.8

3.5. Pediatrician's Judgment and Education

Pediatricians' level of self-efficacy in pediatric medicolegal matters was found to be statistically significant depending on whether they had received seminars, lectures, or training on medical law. 46% of the pediatricians participating in the research had previously received seminars, courses, and training on medical law (medical responsibility). Accordingly, physicians trained in this subject feel more competent in pediatric medicolegal issues (p = 0.00). A total of 28% of the participants had previously experienced a situation related to children brought to court stemming from medical practice. However, there was no statistical significance between the participant's experience of a situation brought to the judiciary due to medical training and their competence in pediatric medicolegal matters (p = 0.68) (Table 5).

Table 5

The Relationship between Pediatricians' Judgment and Education and Competence Levels
		n	mean	SD	Z	p
Judicial review of medical practice	No	150	73.69	23.81	− .400	0.68
Judicial review of medical practice	Yes	59	75.68	24.46	− .400	0.68
Medical Law seminar lecture training	No	112	68.45	24.52	-3.861	0.00*
Medical Law seminar lecture training	Yes	97	80.95	21.54	-3.861	0.00*
The Mann Whitney U test. p < 0.05*

3.6. Demographic Information of Pediatricians and Competence in Pediatric Legal Issues

When the relationship between the title of the pediatricians participating in the research, the professional year, the institution they work for, and their medical law knowledge were examined, there was no statistical significance between the title and the professional year. However, statistical significance was found between the institution they work for. Accordingly, pediatricians in tertiary education, research, and university hospitals feel more competent in pediatric medicolegal issues than public and private sectors (p = 0.01) (Table 6).

Table 6

The Relationship between Demographic Information of Pediatricians and their Level of Competence in Pediatric Medicolegal Issues
Demographic Data		n	Mean	SD	Z	p
Title	Resident	35	76.88	22.76	6.932	0.07
	Specialist	108	70.35	22.69
	Subspecialist	34	77.65	29.07
	Academician	32	80.94	22.05
Working Year	< 5 years	28	76.96	21.03	0.908	0.82
	5–10 years	54	71.76	22.91
	10–20 years	71	75.19	24.35
	> 20 years	56	74.11	26.12
Instutition	Public Hospital	37	69.49	24.44	8.362	0.01*
	University. Research & Training Hospital	137	77.61	23.18
	Private Hospital / Officer	35	66.17	24.33
The Kruskal Wallis test. p < 0.05*

4.1. In general

Two hundred-nine pediatricians participated in the study. Participants were asked if they felt knowledgeable and competent about:

discharge of preterm babies,
treatment of children in life-threatening and non-life-threatening disease states
vaccination and screening programs
inspection without a legal representative
judicial and legal issues regarding disclosure and refusal in cases of suspected abuse.

In addition, the opinions of the child on the discrimination power and participation in the treatment were taken, and it was learned whether they:

received training in medical law
prosecuted or not

First, it was concluded that pediatricians do not feel competent in medicolegal issues related to possible pediatric cases. Since the average proficiency in accepting treatment is 3.19, many pediatricians have expressed their indecisiveness and thought they needed more time, even in such frequent situations. On the other hand, in cases of refusal of treatment, the situation is even worse as the average feeling of self-efficacy of pediatricians is 2.77. However, in case of refusing the treatment, medical, legal, and ethical dilemmas such as the consent of the legal representative, the child's decision, and life-threatening emergency are felt more intensely, and it becomes difficult to determine the rules and procedures to be applied in case of refusing treatment [2]. For this reason, although it is normal for pediatricians to feel less competent in refusing treatment compared to accepting treatment, due to the dilemmas encountered, pediatricians do not feel sufficient for cases where treatment is eventually accepted.

The fact that pediatricians feel more competent in accepting treatment may be due to medical and ethical rather than legal reasons. The doctor whose main duty is treatment and who has taken an oath on this subject is unlikely to experience a dilemma in accepting the treatment. On the other hand, offering and getting treatment to someone who has already come to the hospital does not cause difficulties or conflicts in practice. Therefore, proficiency in this matter may be due to the scarcity of the problems that arise in practice or the problem's natural solution rather than the physicians' legal knowledge.

4.2. Education and Judicial Process

A total of 46% of pediatricians stated that they had previously received seminars and courses on medical law (medical responsibility). It was found statistically significant that the pediatricians who received this training felt competent in pediatric medicolegal matters (p = 0,00). Pieces of training increase the knowledge level of physicians and thus make them feel more competent in medicolegal issues. However, these trainings are generally not held by the Ministry of Health but within scientific events such as congresses or symposiums [21]. This situation shows the importance of education and standardized training organizations that the Ministry of Health should organize to establish a unity of practice.

It should be emphasized that training, such as in seminars, is very superficial. While it needs to produce solutions to the concrete problems experienced in hospitals, most of this training addresses the general responsibility of physicians. The real problem arises when physicians are faced with difficulties in the field. It is seen that even physicians with a master's degree have hesitations about these issues occasionally and even make wrong decisions. Therefore, more than general education is needed for the medicolegal decision-making process of physicians, and the information obtained from this education can sometimes be misleading.

A total of 28% of the participants had experienced judicial and legal processes in some way, having previously experienced a situation brought to the judiciary due to medical practice related to children. First, this rate is high because almost one of every three pediatricians has faced a judicial process. On the other hand, there was no statistical significance between pediatricians' experiences of this situation and their competence in pediatric medicolegal issues (p = 0.68). The fact that pediatricians have a certain experience going through medicolegal processes does not make them feel competent in medicolegal matters. Although it can be thought that the process itself will contribute to the competence of physicians, especially in the forensic process, on the contrary, it has been understood that such a contribution does not exist.

Similarly, since pediatricians need to be more competent and experienced with their judicial process, it is impossible to say they increase their knowledge in medicolegal matters. On the contrary, it is known that exposure to the judicial process causes physicians to behave more recessively and to turn to defensive medicine [23]. For this reason, the risk of making mistakes again by pediatricians who do not feel competent may increase, or at least it should be accepted that judicial processes do not increase the medicolegal knowledge levels of pediatricians and do not make them feel competent. This issue needs to be a separate research topic. It is an interesting result that the physicians who have personally experienced the legal process in the field do not see themselves as competent in such cases.

As can be seen, there is a significant indirect difference between pediatricians' experience of medicolegal processes and their training on this subject. This indirect difference demonstrates the importance of education, as it shows that pediatricians do not feel competent when faced with a judicial process. Thus, education rather than the judicial process can prevent legal and medical errors.

4.3. Working Conditions

When the relationship between the title, professional year, and institution of the pediatricians included in the study and their legal and legal competence levels are examined, there is no statistical significance in terms of title and professional year. However, statistical significance was found among the institutions they work for. Accordingly, pediatricians in tertiary education, research, and university hospitals feel more competent in pediatric forensic and legal issues than those in the public and private sectors (p = 0.01). The fact that physicians working in the private sector are less confronted with forensic issues is a factor in this regard. However, it is interesting that tertiary care physicians consider themselves more competent than physicians working in public hospitals. Normally, there are more medicolegal problems in the state hospital, and therefore the physicians working here might tend to focus more on these issues, but the research has revealed the opposite result.

Interestingly, there is no correlation between the professional title and professional year of pediatricians and their inadequacy in forensic and legal matters. Because the title and professional year are factors that directly affect the knowledge and experience of the physician, it is shown that as the professional seniority of pediatricians increases, they believe that the rate of encountering litigation will be lower [21]. However, considering that the judicial process experience does not affect the competence of pediatricians, the main factor determining the competence of pediatricians in medicolegal matters is the experience rather than education. Supporting this idea is that pediatricians working in tertiary hospitals feel more competent. At this point, non-tertiary-level hospitals are directly aimed at providing health services to the patient rather than education. There are no persons or institutions, such as chiefs or education officers, that physicians can consult directly on medical or legal issues.

In contrast, tertiary hospitals, unlike other-level hospitals, focus on education rather than service delivery. The fact that there are institutions and people who provide training on these issues is effective; however, it is yet to be known whether this education on medicolegalities is sufficient. Therefore, non-educational factors should also be considered in this regard.

Since there is a significant correlation between the training of pediatricians working at the tertiary level and their training, the educational activities of physicians on medicolegal issues should be developed at each level.

4.4. Evaluation of Possible Cases

The first three cases in which the pediatricians feel competent in medicolegal matters, according to the average score order, are related to the hospitalization of a three-year-old child whose general condition is not bad (3.53/5), the admission to the intensive care unit of the four-year-old with a life-threatening illness (3.43/5), and the operation of a 12-year-old child who needs urgent intervention (3,36/5).

Even in the first three possible cases in which pediatricians feel competent, it is seen that they are essentially indecisive; in other words, they are not competent in legal matters. However, these three possible cases are frequently encountered in daily professional life, which does not cause dilemmas in life endangerment, discernment, and consent issues. Higher qualification data is expected from physicians in these cases. Even in everyday cases not subject to medical and legal dilemmas, physicians do not feel competent in medicolegal aspects. For this reason, legal training activities for pediatricians should be carried out.

The last three cases in which pediatricians felt competent in terms of medicolegal aspects, in order of scores, are the refusal of examination and treatment by a fourteen-year-old child who came to the outpatient clinic with a relative who was not a legal representative (2.46/5), the rejection of a fifteen-year-old child who went to the outpatient clinic alone for examination and treatment (2,56/5), and the refusal of only the antibiotic treatment apart from other treatments by a hospitalized 15-year-old patient (2.64/5).

The three possible scenarios in which pediatricians felt the most incompetent all relate to the refusal of treatment by the child without a legal representative. While pediatricians do not feel competent even in cases that are not subject to dilemma, it is quite natural that they do not feel competent in cases subject to legal and ethical dilemmas such as lack of legal representation, power of discrimination, and treatment refusal. However, seeing this result as natural is not a real acceptance but a determination of the situation through comparison in the face of dilemmas. For this reason, while planning the educational activities of pediatricians, especially the situations that may be the subject of dilemmas should be emphasized. As mentioned above, more than just general education is needed for physicians. Especially with specialty associations, training studies should be carried out on concrete problems and concrete cases with a limited number of willing physicians on this subject. More importantly, it will be more beneficial to identify physicians to be trained from almost every clinic and to train these physicians.

However, while evaluating possible cases, an interesting result, in our opinion, is that physicians do not feel adequate regarding the consent of mandatory screening tests for congenital hypothyroidism, phenylketonuria, biotinidase deficiency, and cystic fibrosis (3.29/5) and refusal of screening tests (2.76/5) within the scope of the Newborn Screening Program. The impression of inadequacy is a situation that should be emphasized, and the reasons for this should be investigated separately. Because the mandatory screening tests mentioned are the tests that are regulated by Public Health Law No. 1593 and Health Services Basic Law No. 3359 and are included in the daily routine. In addition, compulsory screening tests have also been the subject of the Constitutional Court (Anayasa Mahkemesi), and the Constitutional Court has found the compulsory screening test regulated by law to be appropriate and proportionate to the requirements of a democratic society [24].

4.5. Child's Decision and Discernment

Discernment (the power of discrimination) is defined as the ability of a person to act rationally and to comprehend the causes and consequences of his actions. It is the key to his capacity to act [25]. The age at which the authority to consent to medical practice begins in children, in other words, the ability to work in medical practice, is a controversial issue in both Turkish and comparative law [3].

In Turkish and comparative law, children under 12 are generally not allowed to decide on medical practice [3, 26]. On the other hand, it is argued that children over the age of 15 may decide on medical practice because they are capable of disposing of all their assets with a will [27] according to the practice of the Court of Cassation and the Turkish Penal Code since they possess the ability to a fault [3].

However, discernment in children is a relative concept and should be evaluated separately for each event [3, 22, 28]. Evaluation of the power of discrimination should be done by a physician, as it is a medical issue [28, 29].

The issue of consent in children between the ages of 15–18 is one of the most difficult issues in medical law. Both the different provisions of the law and the widely variable opinions in the doctrine, on the other hand, the absence of jurisprudence has led to a situation that needs to be clarified. Therefore, it is natural that physicians do not consider themselves sufficient. There has yet to be a consensus on this issue, even among lawyers [22, 28, 30, 31].

A total of 66% of pediatricians say that children under 12 do not have the power to discriminate (while noting 32% should be evaluated on a case-by-case basis), 61% say evaluation must be done on a case-by-case basis for children aged 12–15 years, and 54% say that power of discrimination is present for those aged 15 and over (39% should be evaluated on a case-by-case basis).

Naturally, pediatricians need to make a clear decision on this issue, which is also controversial in law. However, in general, these results largely overlap with the views in the doctrine since only 2% say that children under the age of 12 have discernment, and only 7% of those say that they have no discernment over the age of 15.

4.6. The Child's Decision and the Family's Decision

For minor or non-discriminatory children, the consent of their legal representative is necessary and sufficient [3, 30]. For this reason, the family's decision is decisive for children who do not have the power to discriminate. However, when the decision of the children with the power of discrimination is compared with the decision of the family, Although the consent of the legal representative is a must, three different views emerge: taking the opinion of the child, taking the opinion of the legal representative and the child together, and the consent of the child alone is sufficient [31]. In general, when looking at the current legal regulations, the child's own will should also be taken into account, as well as the legal representative's consent [3]. However, in line with article 70 of Law No. 1219, in cases where the child does not have or is not a legal representative, it is necessary to act by the child's power of discrimination without seeking the legal representative's consent [32].

In a probable case where the decision of the 15-year-old child who is hospitalized in the ward and has the power to discriminate is evaluated according to the family's decision, 42% of the pediatricians stated that the child would not comply with the decision if the family were not present, and 47% stated that if the family accepted the treatment, the child would not comply with the decision of rejection meanwhile 48% were undecided about the impact of the child's decision when the family did not accept treatment. As can be seen, the rate of compliance with the decision of the discriminatory child without a family member or legal guardian is only 16%.

For this reason, pediatricians tend to refrain from complying with the decision of discerning children who are not with their families. However, in line with the legislation and in the child's best interests, if the child decides to perform the medical intervention for the child to exercise his right to health properly, this decision should be considered.

On the other hand, 46% of pediatricians are undecided if the family does not accept the treatment and the child with discernment accepts the treatment.

This high rate shows that pediatricians are in a right and ancient dilemma when the consent of the legal representative and the best interests of the child conflict. In fact, acting with the legal representative's consent is generally necessary in these cases. However, if the child has a concrete and absolute need for medical intervention, such as the need for hospitalization, which is not urgent, but the legal representative does not consent to this, it is possible to intervene depending on a court order by the provisions of Article 24/4 of the Patient Rights Regulation, Article 348 of the Turkish Civil Code and Article 5 of the Child Protection Law. The administration should take the necessary measures to reach the court for such cases [32].

It is understood that physicians are not aware of such procedures either. Essentially, the hospital management should have knowledge of these procedures rather than the physician. It is out of the question for the physician to deal with or follow the court processes in person. Therefore, the main responsibility in this matter falls on the administration. However, in cases where the child's health or life is likely to be harmed, the physician should receive training, and the administration should know what to do if the parent and child refuse treatment.

4.7. Limitations

Our study had some limitations. The lack of standardization of the questions and the subjective nature of the answers are the main limitations of our study. In addition, the outcomes of our study might change if the sample size was larger. In addition, no distinction between pediatricians and residents could be made in our study. Since no recent studies were found in the literature searches, mainly basic legal works were used as references.

The strength of our study is that our findings contribute to the literature due to the need for similar studies on this subject.

It is seen that pediatricians need to gain more knowledge of medicolegal issues. Training on this subject, adding legal education to the curriculum in medical faculties, and organizing regular seminars will help to overcome the lack of knowledge on this subject.

In this regard, comprehensive training should be organized. Physicians who are willing to train should be determined in advance. These physicians should be trained as trainers and determined to be consulted when a problem is encountered in hospitals. When determining these physicians, priority should be given to those with justice or legal education. It should be acted in cooperation with specialist associations. Real problems in practice should be identified, and training should be given on these matters. Education should be given to a small number of physicians. Physicians should be selected according to different hospitals and experience. Training should also be provided, especially at the resident level. It should be ensured that the trained physicians receive updated training at least once a year.

Ethics approval and consent to participate

Ethical approval was obtained from Izmir Bozyaka Training and Research Hospital Ethics Committee on 06.06.2022 with the number 2022/113. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from the participants.

We have read the current "BMC Pediatrics" and will comply with the instructions and accept the conditions therein. The manuscript has not been and will not be submitted to any other journal while it is under consideration by "BMC Pediatrics." We transfer all copyright ownership of the paper mentioned above to "BMC Pediatrics" if the work is published.

Consent for publication

Not applicable. There is no personal information provided in this paper.

Availability of data and materials

All data generated or analyzed during this study are included in this published article

Competing interests

The authors declare no conflicts of interest.

Funding

The authors did not receive support from any organization for the submitted work.

Authors' contributions

Cambaz Kurt N and Doğramacı YG designed the study; Cambaz Kurt N and Doğramacı YG collected and analyzed data; Doğramacı YG, Hakeri H wrote the manuscript. All authors participated in drafting the manuscript. All authors read and approved the final version of the manuscript

Acknowledgments

Not applicable

Author details

¹Department of Pediatrics, Pediatrician, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, Istanbul, Turkey

²Health Law Scientist, PhD, Nevvar Salih İsgoren Public Hospital, Izmir, Turkey

³Head of Medical Law Institute, Faculty of Law, Professor Doctor, Ozyegin University, Istanbul,Turkey

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No competing interests reported.

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Determination of Attitudes and Knowledge Levels of Pediatricians About Pediatric Medicolegal Problems in Turkey

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Abstract

1. Introduction

2. Materials And Methods

2.1. Study Design

2.2. Case Scenarios

2.3. Data collection

2.4. Statistical Analysis

3. Results

3.1. Demographic Information of Pediatricians

3.2. Case Scenarios

3.3. Physicians' Assessment of the Child's Decision

3.4. Pediatricians' Thoughts About Discernment in Children

3.5. Pediatrician's Judgment and Education

3.6. Demographic Information of Pediatricians and Competence in Pediatric Legal Issues

4. Discussion

4.1. In general

4.2. Education and Judicial Process

4.3. Working Conditions

4.4. Evaluation of Possible Cases

4.5. Child's Decision and Discernment

4.6. The Child's Decision and the Family's Decision

4.7. Limitations

Conclusion

Declarations

References

Additional Declarations

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