Navigating the ethics of removing benign melanocytic nevi in children
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Key takeaways:
- According to Sami K. Saikaly, MD, if the treatment is not medically or emotionally necessary, the procedure should be avoided.
- Medical benefits must be evaluated from the patient perspective, not the parents.
Dermatologists should avoid the removal of benign nevi from children that are not of a consenting age, regardless of the parents’ preferences, according to an article published in the Journal of the American Academy of Dermatology.
“Medical decision-making should be focused on the patient’s best interests,” Sami K. Saikaly, MD, a clinical assistant professor in the department of dermatology at the University of Florida College of Medicine and one of the article authors, told Healio. “When the patient is a child, this becomes more nuanced, as social, developmental and emotional implications of the medical procedure must be considered.”
In a query written to the “Ethics Journal Club” in the Journal of the American Academy of Dermatology, a practitioner described a scenario where a father brought in his children, aged 11 and 6 years, requesting their facial benign melanocytic nevi be removed because they were “unattractive.”
While the practitioner explained that the lesions were benign, the father insisted that they be removed. On the other hand, the children were unbothered by their lesions and instead expressed fear over the procedure. In an ethically gray situation such as this, the writer asked how a dermatologist should proceed.
If a treatment is not medically necessary, Saikaly explained, and the implications on the child’s social, developmental and emotional well-being are unclear, then the procedure should be avoided until the child is of a consenting age.
According to the American Academy of Pediatrics, dermatologists are encouraged to obtain assent from minors whenever possible, as long as there is no clear pressure for parents or peers.
“The age at which this is possible will vary on a case-by-case basis,” Saikaly added. “It is the physician’s ethical duty to explore the patient’s maturity, decision-making stability and personal identity understanding.”
In this scenario, Saikaly explained, where the father — and not the children — is insisting on the removal of nevi for aesthetic reasons despite the nevi having only a 0.0005% likelihood of progressing to melanoma before the age of 40 years, the procedure should be avoided.
The potential risks for pain, bleeding, scarring and infection do not outweigh the aesthetic benefits of removing the nevi, according to Saikaly and colleagues. Furthermore, the primary motive of the father’s request is not on behalf of the children’s health, as they seem unbothered by their lesions.
If a parent further insists on the procedure against the recommendation of the practitioner, Saikaly recommends two options of how to proceed.
“It is the physician’s duty to further explore why the physician and parental/guardian goals are incongruent,” he said. “The physician should undergo an open-ended, nonjudgmental discussion with the patient’s parent(s)/guardian(s) to further assess their comprehension, motives and decision-making capacity.”
Saikaly stressed that the physician is not obligated to abide by the parent’s request; however, if common ground cannot be reached after the aforementioned option is exhausted, the physician may offer a referral for a second opinion.