Medical Perspectives: Bioethics/Ethics and the Duties of Medical Professionals and the Nature, Advantages, and Limits of Public Health Approaches
© Springer Science+Business Media Dordrecht 2015Ben Mathews and Donald C. Bross (eds.)Mandatory Reporting Laws and the Identification of Severe Child Abuse and NeglectChild MaltreatmentContemporary Issues in Research and Policy410.1007/978-94-017-9685-9_9
9. Medical Perspectives: Bioethics/Ethics and the Duties of Medical Professionals and the Nature, Advantages, and Limits of Public Health Approaches
Antioch University New England, Keene, NH, USA
KeywordsChild abuse and neglectPublic healthBioethicsMedical cliniciansMandatory reportingReconcilable duties
Mandatory reporting of suspected child abuse highlights the intersection of clinical practice and public health, underscoring that medicine is practiced within a social context. “Child abuse did not exist in meaningful societal terms until it was named and measured.” Mandatory reporting also highlights the intersection of law, professional standards, and ethics. Ethical issues associated with mandatory reporting include breaching confidentiality and perceived adverse consequences of reporting.
Effective prevention requires the linked efforts of individual clinicians who observe – and report – suspected maltreatment on a case-by-case basis and robust public health monitoring, intervention and prevention strategies at the family, community and societal level.
The bioethical principles of autonomy, beneficence, non-maleficence, and justice as reflected in professional codes and the values articulated in the evolving ethics of public health define the obligations and duties of each. While clinical medicine focuses on the individual patient and public health serves the entire community, they intersect in preserving the dignity of the human person and protecting the vulnerable. Society is ethically justified in imposing limits on the confidential relationship between patient and provider to prevent maltreatment, and clinicians may ethically honor mandatory child abuse reporting laws to protect individuals and advance the public good. Not reporting is not ethical; “professional involvement in the area of child abuse can be thought of as part of a professional’s responsibility to the community he or she serves.”
The Intersection of Clinical Medicine and Public Health
Henry Kempe alerted the medical community to the clinical indicators of child abuse and catalyzed the national response that led to mandatory reporting of suspected abuse (Kempe et al. 1962). In the words of Jonathan Mann “…child abuse did not exist in meaningful societal terms until it was named and measured” (Mann 1997, p. 10). Mandatory reporting thus highlights the intersection of clinical practice and public health and underscores the reality that medicine is always practiced within a social context (Pellegrino and Thomasma 2004). Public health resources complement and supplement the care and expertise of medical providers in treating and preventing child maltreatment.
Mandatory reporting also highlights the intersection of – and potential conflicts between – law and professional ethical standards:
With few exceptions, reporting statutes place limits on confidentiality and privileged communications. Professional discretion and judgment are rarely given consideration in reporting requirements. As a result, laws that require reporting suspected child abuse and neglect in professional contexts often conflict with basic professional values and ethical principles. (Kalichman 1999) Providers who are fully aware of their legal obligation to report suspected abuse, however, may choose not to report when they believe that doing so is unethical. (Kalichman 1999, p. 42)
Clinicians1 see and focus on individual patients, with clear obligations to those patients stemming from professional standards, law, and general ethical principles. The legal obligation to report maltreatment stems from an equally clear recognition of society’s collective responsibility to protect children and the corollary need to assess the nature and magnitude of risks to children and to evaluate the efficacy of interventions:
The clinical relationship centers on a vulnerable, anxious, dependent, often suffering individual person…. For public health physicians and nurses the relationship is with the whole society. The end or purpose of the relationship is the good of humans as a collectivity, the common good…. Their [public health physicians and nurses] “patient” is society and its ills. They serve the good of society’s individual members secondarily by assuring a healthy community in which the individual can flourish. (Pellegrino and Thomasma 2004, p. 21)
It’s been stated that the central dilemma in public health is balancing the rights of the individual against those of society (Richards and Rathbun 1999), and it cannot be disputed that clinical medicine and public health have different immediate ends. Not infrequently, these ends compete or conflict. Some go so far as to suggest that this conflict is inevitable and that “to ignore the ethical tensions between communal and individual interests would be, prima facie, poor professional practice” (Hester 2004, p. 1). “A truly dynamic philosophy of society recognizes the necessity of a continuously negotiated struggle to balance individual and common good” (Pellegrino and Thomasma 2004, p. 19). Historic challenges to compulsory vaccination2 and contemporary controversies about HIV/AIDS testing, partner notification (Bayer and Toomey 1992), directly observed therapy for tuberculosis (Bayer and Dubler 1993), and access to scarce health resources all underscore that such conflicts are real and not theoretical.
To reconcile the interests of individuals and the community when they conflict (or, realistically, to decide and to act in the face of this tension) requires, inter alia, an understanding of the ethical values that underlie clinical decision making and those of public or social health. In the specific instance of child protection and mandatory reporting, it is suggested these interests converge and are arguably more complementary rather than antagonistic: “Clinical medicine and social medicine intersect in preserving the dignity of the human person” (Pellegrino and Thomasma 2004, p. 16). “Despite personal feelings about the reporting process, practitioners are urged to maintain compliance with their legal mandate and function as child advocates. Professional involvement in the area of child abuse can be thought of as part of a professional’s responsibility to the community he or she serves” (Alvarez et al. 2005, p. 326).
Societal acknowledgment of and response to child abuse, the emergence of biomedical ethics as a distinct field, and the evolution of a corresponding ethics of public health all occurred fairly recently – within the past 50–60 years. During this period the boundary around the individual therapeutic encounter between physician and patient eroded as medical technology introduced new therapies but also posed challenging questions about who should have access to these therapies and who should decide.3 During the same period Kempe and others shifted the focus of child protection beyond the responsibility of medical providers to include a wide range of “mandated reporters” inside and outside the medical community and demanded a societal response. Child protection is often characterized as the conflict between parental rights and society’s duties to protect its vulnerable members. Among Kempe’s contributions was the recognition that child welfare is not an exclusively private, family matter but an important public health concern, i.e., that child welfare is the parents’ responsibility unless and until they breach that obligation, at which point the community can and must intervene.
This chapter describes the public health role in preventing violence and abuse, the benefits and limitations of that approach, and the interplay with mandatory reporting. The principles of biomedical ethics and the ethical standards and values underlying both clinical practice and public health practice are summarized as they apply to mandatory reporting. Clinical ethics and the ethics of public health lead to the same conclusion about mandatory reporting, albeit from different perspectives. Society is ethically justified (if not obligated) in imposing limits on the confidential relationship between patient and provider to prevent child maltreatment. And clinicians may ethically honor mandatory child abuse reporting laws to protect individuals and advance the public good. Not reporting is not ethical.
What Is Public Health?
Definitions of public health range from detailed descriptions of the many and varied roles of public health workers (sanitation, restaurant inspections, vital statistics, disease control, environmental monitoring, education, health promotion) to the broad Institute of Medicine definition: “Public health is what we, as a society, do collectively to assure the conditions for people to be healthy” (National Research Council 1988, p. 1). Thus framed, it is clear that the focus of public health is on populations and communities, rather than on individuals. Generally (though not exclusively) a function of state, federal, and local government, the public health workforce includes clinicians – physicians, nurses, mental health workers – and a range of other specialists, not all of whom belong to a distinct profession or are bound by a professional code of standards like those for the healing professions (physicians, nurses, psychologists) (AMA 2004; APA 2010; ANA 2009).
The Role of Public Health in Preventing Violence and Child Maltreatment
Public health’s responsibility to prevent child maltreatment arises from two sources: First, there are practical and professional limits on an individual clinician’s ability to provide the spectrum of services needed to fully protect children who may have been maltreated and to prevent further abuse and, second, from the realization that intentional violence in all forms (e.g., domestic partner violence, elder abuse, child abuse, homicide, and suicide) is in fact a public health issue amenable to traditional (and creative new) public health interventions.
Physicians are bound to address maltreatment and other forms of violence as they present in the clinical setting, within the limits of their professional competence and the immediate case. Some are concerned about a perceived trend toward “medicalizing” the wide range of social factors which contribute to violence and suggest that going beyond the parameters of the clinical case drains resources from others and dilutes their professional roles. By reporting suspected abuse (i.e., without the need to investigate or prove intent), clinicians can enlist and engage the resources and expertise of child protective services, public health, and, rarely, law enforcement. “Handing off” cases by reporting enables clinicians to adhere to what’s been termed “clinical parsimony” and focus on delivering services they are prepared to do best: caring for individual patients.
Violence, including violence against children, was once perceived as primarily a law enforcement matter. It is now recognized as a public health problem that can be studied, understood, and prevented. It was not always so. Public health traditionally dealt with aspects of infectious disease: identifying agents that caused or transmitted it and reducing or eliminating conditions that facilitated its spread through immunization, environmental, and educational campaigns. Only within the last decades of the twentieth century was violence – including child abuse, elder abuse, and domestic partner violence – recognized as a public health problem. Public health interventions and strategies were adapted and applied to prevent violence and change social norms surrounding it. In the words of former US Surgeon General C. Everett Koop, “[P]ublic health is in the business of continually redefining the unacceptable” (Rosenberg and Fenley 1991, p. v.).
Initial public health concerns about violence and abuse centered on the immediate consequences and the human, societal, and economic costs of intentional injuries and deaths. Research about the long-term consequences of abuse now furnishes additional justification for addressing child maltreatment as a public health issue and for invoking the tools of public health, including reporting and surveillance. It is now known that early childhood trauma has lifelong health consequences.
Given the observed associations with childhood trauma and a range of problems – substance abuse, teen pregnancy, depression, anxiety, sexually transmitted diseases, smoking, and obesity – in later life, Mercy and Saul (2009) cited in Zimmerman and Mercy (2010) conclude:
[P]reventing maltreatment has come to be seen as an important factor in enhancing the overall health and wellness of the population. [A]buse, neglect and other traumatic events can take a serious toll, contributing to health problems over a lifetime. (Zimmerman and Mercy 2010, pp. 4–5)
The US Surgeon General’s 1979 report, Healthy People, outlined a national prevention strategy with specific objectives for reducing homicide, suicide, and child abuse rates and identifying associated risk factors; the report also called for improving the reliability of data on child abuse and family violence (HEW 1979). Essential to this strategy is surveillance, a basic public health tool for collecting and analyzing data to define and measure the scope and magnitude of the problem, develop intervention strategies, and evaluate their efficacy (Rosenberg and Fenley 1991, p. ix). Mandatory reports4 form the cornerstone of these surveillance efforts. Despite jurisdictional variation in who must report and questions about the extent of underreporting, public health reports provide baseline data, the starting point for assessing the extent and magnitude of the problem and the ability to observe and monitor trends.
Initial public health initiatives addressed homicide and suicide, especially among young people:
The early successes in youth-violence prevention paved the way for a public health approach to other violence problems, such as intimate partner violence, sexual violence, and child maltreatment. Efforts were made to document each problem, understand the risk and protective factors associated with each type of violence, and begin building the evidence base for prevention. (Dalhberg and Mercy, February 2009, p. 169)
By shifting the focus from individual and family dynamics to community-based and societal strategies, public health initiatives complement and supplement patient-level interventions. Education and promotion efforts inform, educate, and raise societal awareness of maltreatment and define (and redefine) the limits of the unacceptable (as, e.g., with parental attitudes toward corporal punishment). Consistent, uniform ongoing surveillance (building on mandatory reports) and the application of epidemiologic techniques support new interventions and monitor and assess their efficacy. By virtue of their local, state, and national presence, public health agencies can be, on the one hand, accessible and responsive and, on the other, capable of assimilating and analyzing national-level data. Public health officials can monitor shifts in the many conditions that put children at risk and develop prevention strategies at the individual, family, community, and societal levels. Reporting and other surveillance data monitor and measure these initiatives.
The goal of public health is to establish a continuum of services that extends beyond individual families to include “…public education efforts to change social norms and behavior, neighborhood activities that engage parents, and public policies and institutions that support families” (Zimmerman and Mercy 2010, p. 6). Initiatives promote collaboration among community partners such as early childhood education, schools, police, faith-based organizations, libraries, and neighborhood recreation centers with the shared aim of prevention. These approaches reflect a societal shift from reactive to proactive strategies that can reach more families, in non-stigmatizing settings, and prevent maltreatment and other forms of violence before they occur.
The Centers for Disease Control and Prevention (CDC) Public Health Leadership Initiative, a multiyear project launched in 2009 with funding from the Doris Duke Charitable Foundation, identified best practices to promote “…safe, stable, and nurturing relationships…” for all children, to support a strong national public heath prevention system. Public health agencies are uniquely qualified for addressing maltreatment:
There is compelling scientific research base that makes the case for preventing maltreatment as a strategy to promote health and prevent disease across the lifespan.
The child protection system sees only a fraction of the total number of children who experience abuse or neglect, and its involvement is after the fact.
It is not practical, financially feasible, or even appropriate to provide individualized social services to all families.
Public health efforts have successfully addressed other health concerns by using a mix of education, communication, and policy changes: Consider the use of bike helmets or “back-to-sleep” campaigns.
Public health is experienced at addressing complex health issues (e.g. smoking, substance abuse) that require sustained, multiprong strategies that have been adapted to changes over time.
Public health campaigns are often multidisciplinary, cutting across several service systems and engaging a variety of professionals as well as “regular” people.
Limitations of Public Health
Public health’s role in child maltreatment is necessary but not sufficient. The factors that make public health an effective complement to clinical medicine with regard to abuse are among its limitations:
[A]lthough the final aim of health protection is to assist and safeguard the individual human being, public health is instrumentally and strategically committed to perform at the level of populations, seeking epidemiological knowledge and proposing health care measures that can only be achieved at the social level. (Kottow 2012, p. 37)
Effective prevention requires the linked efforts of the clinicians who observe – and report – suspected maltreatment on a case-by-case basis and robust public health monitoring and prevention strategies.
The initial clinical encounter leading to a differential diagnosis that includes possible maltreatment is the catalyst for all subsequent protective and preventive services. Clinicians who suspect abuse must, by law, report it to initiate protective services for the benefit of the index case, to engage child protective services, and to contribute to community-level surveillance. A substantial proportion of mandated reporters – 40 % is the most commonly cited datum (Alvarez, Donahue, Kenny, Cavanagh, and Romero 2005)5 – however, indicate that on at least one occasion they did not report suspected abuse. Many who acknowledge not reporting cite what they believe to be overriding ethical concerns: the duty of confidentiality6 to patients or families, which is most commonly cited, potential “double agentry” (i.e., perceiving reporting as “service to the state” that compels them to serve the interests of someone other than the client) (Stadler 1989), concerns that reporting will undermine or abrogate the trust required to establish and maintain a therapeutic relationship, and fears that reporting will cause greater harm than good to the abused individuals.7
The healing professions (physicians, nurses, and psychologists) have codes of conduct that articulate aspirational goals and enforceable standards of practice for members of the profession. The codes commonly require achieving and maintaining professional competence (with legal corollaries in licensing and credentialing regulations) and affirmative obligations to prevent harm. The American Medical Association Code of Medical Ethics (AMA 2004), the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (APA 2010), and the American Nurses Association (ANA) Nursing Code of Ethics (ANA 2009) all emphasize the primacy of the duty to protect patient confidence, yet all explicitly acknowledge that there are legitimate limitations on that duty, most notably when required by law to report.