Ethical issues inChild Abuse

LAUREN BURGE, MD

CHILD ABUSE FELLOW, PGY-5

TEXAS CHILDREN’S HOSPITAL

Disclaimer

I am not a lawyer

I am not giving legal advice

Should you have any questions, please contact an actual lawyer oryour risk management team

Objectives

1. Recognize common risk factors for child abuseand neglect

2. Discuss ethical issues surrounding child abuseand neglect

3. Describe the best reporting processes oncechild abuse or neglect is suspected

4. Identify barriers to reporting child abuse andneglect

CHILD abuse

It’s Scary

It’s Sad

It’s important

4 Pillars of Ethics

Autonomy- “At a minimum, personal autonomy encompasses

self-rule that is free from both controlling interference by others andlimitations that prevent meaningful choice…”

Justice- includes, but is not limited to distributive justice, which

pertains to, “fair, equitable, and appropriate distributions of benefitsand burdens determined by norms that structure the terms of socialcooperation.”

Beneficence- contributing to the welfare of others

Non-maleficence – refraining from causing harm to others

Beauchamp, T. and Childress, J. Principles of Biomedical Ethics. Oxford University Press, Seventh Edition. 2013.

4 Pillars of Ethics

The pillars may not all align with eachother

Goal is to achieve balance

Not always easy

Let’s practice!

Case 1

2 month old male admitted to PICU with intracranial bleeding, skullfx, respiratory failure, BL femoral CMLs, and multiple rib fractures

Mother’s boyfriend admits to shaking the child vigorously to get himto stop crying

Mother reports that her boyfriend has done this multiple times toquiet the baby

There is a 2 y/o sibling at home

What do you do?

Discuss the 4 pillars

Case 2

4 month old weighs <1%, ht <1%, FOC normal

Mother just moved to your city and this is her first PCP apt since thechild’s new born apt

Mother reports to mixing 1 scoop of formula to 4 oz of water

Mother reports the child is always fussy and is a difficult feeder

Mother has 4 other children and lives with her own mother and sister

Multiple care takers in the home

What do you do?

Discuss the 4 pillars

Risk Factors

What are the risk factors?

Beware implicit bias

Abuse or neglect occurs in allfamilies, cultures, and socioeconomicclasses

Confidentiality

What is HIPAA?

How is HIPAA applied to cases of childabuse and neglect?

May share certain medical impressionswith law enforcement and CPS

Reporting

Report immediately, but professionals have 48 hours to make a report (Texas Family Code Sec.

261.101)

May report anonymously (TFC Sec. 261.201)

Limited immunity from criminal & civil liability (TFC Sec. 261.106))

Consider gathering relevant information before reporting if safe to do so and if thiscan be done timely

Requires mandatory reporting of abuse in every state bydesignated personnel, including healthcare workers, educators,social workers, and law enforcement personnel.

Mandated Reporter

Child Abuse Prevention & Treatment Act(CAPTA) 1974

What the law says about reporting

Reporting Suspected CHILD ABUSE

www.txabusehotline.org

1-800-252-5400

• In the State of Texas, reporting suspected child abuse andneglect is required

• The purpose of reporting is to trigger an investigation, andto protect children as applicable

• When reporting, you are acting on the child’s behalf

• Increased safety for the child

• Resources for caregiver(s)

Disclosures

Should a provider disclose to afamily that a CPS report hasbeen filed?

Disclosures

Should a provider disclose to a family that aCPS report has been filed?

Disclosure may help maintain the therapeutic relationship

Always put patient’s safety first

If patient safety is an immediate concern, call lawenforcement, CPS, Security and Risk Managementimmediately

Disclosure must be objective

CPS is not intended to be punitive. Can also be used forsupport resources

Disclosures

Be aware of “medical kidnapping” You cannot keep a child against a parent’s will without having

gone through the appropriate avenues (law enforcement /court orders)

Enlist the help of CPS and Risk Management (TCH RiskManagement is available 24/7 through the page operator)

Is it ethical to have a child abuse consultantinvolved in the child’s care without the care-takersknowledge? Maybe - if the patient’s safety is an immediate concern or other

circumstances warrant it

Medical Child Abuse