title: Ethical analysis as a tool for addressing treatment controversies: radiotherapy timing in children with orbital rhabdomyosarcoma as a case example.
abstract: OBJECTIVE
  The treatment of orbital rhabdomyosarcoma is a topic of debate between North American and European clinicians, with the utility of radiation therapy as part of initial management in question. Despite differences in philosophy, the dominant North American approach of upfront radiation and the dominant European approach of radiation only in the event of recurrence yield a similar rate of overall survival. We sought to identify the ethical arguments for each approach.
  
  
  METHODS
  Established moral principles and appeals in contemporary medical ethics were utilized to identify the ethical arguments supporting each treatment approach. The potential for technologic advances to alter the analysis was considered.
  
  
  RESULTS
  Emphasizing the principle of beneficence, the North American approach seeks to reduce recurrence rates. In contrast, the European approach seeks to avoid radiation-induced sequelae, emphasizing the principle of nonmaleficence. Both approaches are based on well-established ethical principles, evidence, and clinical experience. Thus, both approaches currently appear to have legitimacy and should be included in the informed consent process. However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior.
  
  
  CONCLUSIONS
  Ethical analysis can aid in addressing challenges that arise when professional practices and perspectives differ in the management of cancer patients.
authors.affiliation: Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Farnia
authors.affiliation: Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.
authors.forename: Mary A
authors.initials: MA
authors.lastname: Majumder
authors.affiliation: Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas. Electronic address: apaulino@mdanderson.org.
authors.forename: Arnold C
authors.initials: AC
authors.lastname: Paulino
mesh_terms: D000066491:Clinical Decision-Making / Q000941:ethics*; D026689:Ethical Analysis / Q000379:methods*; D009656:North America; D009918:Orbital Neoplasms / Q000532:radiotherapy*; D018787:Radiation Oncology / Q000941:ethics*; D011878:Radiotherapy / Q000941:ethics*; D012208:Rhabdomyosarcoma / Q000532:radiotherapy*; D018570:Risk Assessment / Q000941:ethics; D014481:United States
keywords: Rhabdomyosarcoma; ethics; late effects; orbit; pediatric; radiotherapy