Fundamental Principles of Bioethics and Their Implementation in the Paediatric Intensive Care Unit: Clinical Complexities and the Imperative for Structured Ethics Education.

Paediatric intensive care units (PICUs) are highly complicated and challenging clinical environments where life-or-death decisions must be made urgently, often under conditions of uncertainty and significant emotional pressure. This review examines the practical application of the four fundamental principles of bioethics - autonomy, beneficence, non-maleficence and justice - in PICUs, with a particular focus on the Greek healthcare context. Children's autonomy is inherently limited, necessitating parental or guardian involvement, yet conflicts often arise when adolescents express preferences that diverge from those of their families. Clinicians must also balance beneficence and non-maleficence in high-risk or emergency interventions, frequently with incomplete information, especially when it comes to complex clinical cases or in children with many comorbidities or congenital health issues. Justice is challenged by scarce resources, compelling clinicians to make ethically correct decisions regarding the allocation of beds or equipment or various types of treatment without standardised institutional guidance or appropriate protocols. In Greece, structured ethics education and formal ethics committees are limited, contributing to variability in practice and an increase in moral distress among healthcare professionals. Given these circumstances, it is considered pivotal to enhance ethics education through curricula, practical workshops and training in communication and to improve the support from each institution in order to strengthen clinicians' ethical competence, gain public trust and, most importantly, improve patient care. The integration of international guidelines and the provision of psychological support are essential to promote sustainable and ethically correct practice in PICUs.