The Moral Abdication of The Academy [Muldoon]

A few days ago I ran across a brief news item out of Aspen, Colorado. A pair of campers on a rugged back country hiking trip along Conundrum Creek Trail in the Maroon Bells area ran into a bit of difficulty with some late spring snowfall and cold temperatures. Some of their camping equipment broke, they could not prepare food, and thought they might be getting frostbite. So they did what any sensible 25-year-old would do, they used their cell phone and called for help. Pitkin County Sheriff's office deployed deputies and a mountain rescue team of some 17 individuals to locate the two campers on the trail about six miles in, and escort them (uninjured and able to walk on their own) back to civilization. I guess there is a reason it is called Conundrum Creek.

I tell you that story so that I can tell you this story:

What image comes to mind when you think of a Pediatrician? Perhaps it's the jovial balding man with the plaid jacket and the bow tie who dons a clown nose and tells 'dad jokes' in the exam room. Or the earnestly pleasant fellow who insists, "Call me Doctor Tim!", and makes duck-quacking sounds to amuse the children. Maybe it's the matronly "Aunt Mabel" type who gently admonishes you on the best way to treat diaper rash. Or the fresh-faced young woman with the child-sized stethoscope draped around her neck who coos and babbles at your newborn? Authoritative or jovial, stern or easygoing, pediatricians come in all shapes and sizes, but surely must be benign and lovable, because they take care of babies, right? Everybody loves a baby goat or a baby elephant, so who wouldn't love a baby doctor?

The American Academy of Pediatrics (AAP), founded in 1930, is by far the largest professional association for Pediatricians in the USA, proudly describing their membership thusly:

We are 67,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.

While certainly the AAP and its various sub-committees have been instrumental in many advances in the medical and surgical treatments of major medical problems affecting children, the organization has a less savory side.

When I began my pediatric training in the mid 1980s it was expected as a matter of course that pediatric residents would automatically join the AAP. It was axiomatic that "pediatrician = AAP member". The mantra in those days was that we were to be "advocates for children". The pediatrician was to utilize his expertise to enhance, fortify and augment parents' ability to raise healthy children. The pediatrician and the parents, as a team, endeavored to help children become functioning adults, with well-rounded physical, mental and social capabilities. We were taught to respect the cultural and ethnic background of each family. Somewhere along the way, there began a shift from augmenting and enhancing, to overruling and usurping parents.

The AAP issues numerous policy statements, intended to address particular pediatric health issues authoritatively, from a position of being subject matter experts. These policy statements originally served as 'guidelines' for pediatricians, but have evolved to become the 'standard of care' for general pediatricians in their daily practices. AAP positions are cited as gospel and deviations from them are shunned. Busy pediatricians nearly always defer to the expert position, as the path of least resistance. Also, AAP statements are not just aimed at practicing pediatricians. More and more they are aimed at public policy makers, legislators and government agencies. I have been noticing some unsettling trends and techniques among the AAP's statements. Let's look at a few examples.

EXAMPLE #1: Avoiding stigma

"Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults, and Families"

A recurring theme in AAP Policy Statements is the non-judgmental or "avoiding stigma" approach.

For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame; however, as addiction became understood as a medical disorder, clinical terminology has shifted along with a growing awareness of harm of stigmatizing language in medicine.

As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of infants, children, adolescents, young adults, and families. In this policy statement, the AAP provides 3 specific recommendations, accompanied by a table that presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and explanations for each.

By deeming certain language to be "problematic", and actively denying any role of morality (either social or individual), the message is clear: i.e., there is nothing wrong about drug use as a recreational lifestyle, and if you suffer adverse effects from that lifestyle, it's because you are a victim. The AAP, by claiming to de-stigmatize language, and removing morality from the equation is actually promoting a different stigma, that of an individual with no 'agency', no ability to act in their own informed best interests. This erasure of individual responsibility goes directly to another common thread that runs among the AAP Policy Statements, the expanding definitions of childhood, and autonomy.

EXAMPLE #2: Blurring developmental lines

"Adolescents and Young Adults: The Pediatrician’s Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis "

The HIV epidemic persists in the United States despite great progress in treatment and continued efforts to identify people living with HIV and AIDS. At year-end 2018, an estimated 1 173 900 people 13 years or older were living with HIV infection in the United States, of whom 47 800 (4%) were adolescents and young adults (hereafter referred to as youth) 13 to 24 years of age.

One technique that I see frequently in AAP documents is deceptive or misleading conflation of age groups when discussing certain issues. The linked article lumps HIV statistics together for ages 13 through 24, clearly disparate ages in terms of types of sexual activity, ability to consent, vulnerability to grooming/trafficking and sexual maturity.

EXAMPLE #3: Intentional distortion and misrepresentation of statistics.

"Firearm-Related Injuries Affecting the Pediatric Population"

"Pediatric Firearm Injury Mortality Epidemiology "

Firearms injury and fatality stats are frequently lumped together from ages 0 -19. This gives the impression that all children are at risk and supports a narrative of an epidemic of childhood firearm risk.

The [overall age 0-19] firearm injury mortality rate in 2019 was 4.15 per 100 000

When broken down into 5-year age groups (0-4, 5-9, 10-14, 15-19) a very different picture emerges. Clearly, firearms deaths in children and adolescents are predominantly among individuals in their late teens by more than 20-fold. (Graph adapted from CDC Mortality Data)

When you break it down by race and sex, the disproportionate mortality from firearms among black males aged 15-19 is even more stark, but discussion of moral and societal root causes for that must be inconvenient, as it is noticeably absent from AAP papers on the subject.

More from the AAP:

In 2019, firearm injuries surpassed motor vehicle collisions to become the leading cause of death for youth aged 0-19 years in the United States, after excluding deaths due to prematurity and congenital anomalies.

So, in other words, what they are saying is that firearms injury from all causes (homicide, suicide, accidental) is the leading cause of death if you ignore the leading causes of deaths. Let that sink in for a moment. I can see only one reason for phrasing the statistics this way and that is solely to magnify the significance of firearm deaths. Also, the comment that firearm injuries surpassed motor vehicle collisions glosses over the fact that this was largely due to decrease in motor vehicle deaths rather than an increase in firearm deaths.

EXAMPLE #4: Expanding the definition of childhood while also granting autonomy to immature individuals

"Sexual and Reproductive Health Care Services in the Pediatric Setting"

Pediatricians are an important source of health care for adolescents and young adults and can play a significant role in addressing their patients’ sexual and reproductive health needs, including preventing unintended pregnancies and sexually transmitted infections (STIs), including HIV, and promoting healthy relationships.

At its inception, the field of Pediatrics self-described as the medical care of children. As time passed, further subcategories of childhood emerged. Advances in newborn care and prevention of common infectious diseases led to a re-categorization into Newborns, Infants and Children. In the 1980s, further expansion defined the transitional phase from child to adult as a unique category, and Adolescent Medicine was born. Now, more recent articles from the AAP speak of Newborns, Infants, Children, Adolescents and Young Adults. Mission creep aside, this has two results. One, it expands the definition of childhood even further, and two, it blurs the line between childhood and adulthood.This creates the ironic situation where childhood is extended well into the 20's, while simultaneously granting pre-teens the autonomy to make life-changing decisions about sexuality and sexual development, such as puberty blockers, male or female hormone enhancement, or surgical genital mutilation.

For decades, Adolescent Medicine specialists have planted and nourished a notion of autonomy and confidentiality between the adolescent and the physician. There comes a point however, when claiming to affirm a pre-teen or teen's feelings or self-image (no matter how delusional it may be) comes into conflict with the parents' lifelong commitment, rights, and responsibilities as the guide for that youth's development from child to adult. At some point, a physician as counselor encouraging a youth to reject the culture, traditions and mores of his/her parents drives a wedge between child and family.

These are just a few examples of trends and attitudes that are present within the AAP today. These observations are subtle, and don't make for sensational headlines, but they do reflect a pattern and an attitude. While couched in generally inoffensive terms, and ostensibly motivated out of a desire to improve the health of children, the underlying message shapes up to be potentially destructive of the family and likely will erode trust between families and pediatricians.

The AAP lists many dozens of position papers on a wide range of topics. If you want to read more in depth, or have an area of particular interest you can find more here.

If there is an overarching theme in all of this, it is that the AAP has, for whatever reason, sidestepped the moral aspects of child rearing in favor of a veneer of science and expertise, while diminishing the role of parents, extended family and community. They seem to be catering to a new constituency (policy makers and government agencies) and ignoring the old constituency (families), using youth as bargaining chips in the process. By willfully accepting a moral vacuum, the AAP and its member pediatricians are enabling an environment where anything goes. They have abdicated their responsibility as advocates for the well-being of children.

The most noble aspiration of parenthood (or a career as a pediatrician) is reaching the point where that child is no longer dependent on you. Preparing a child for adulthood entails instilling the ability to critically assess a situation , weigh the options of any course of action and anticipate outcomes, some of which may not be the outcome you desired. Disappointments happen. Mature individuals learn to adapt. These capabilities require an understanding of right and wrong, in order to weigh the consequences of actions. Any discussion of childhood health, (whether it be gender confusion, firearms, sexuality, drugs or any of the other hot-button issues) that ignores or denies morality is doomed from the outset. By ignoring the role of morality, religion, tradition and culture the AAP has lost its way in the wilderness. Getting back on the right path will take more than a mountain rescue team, it will require a moral reawakening. Returning to my opening paragraph, this then, is the true conundrum of our time.

posted by Open Blogger at 11:00 AM

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