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Respect for autonomy, beneficence, non-maleficence, and justice. The four principal tenets of medical ethics that every physician is sworn to uphold. The principles of beneficence and non-maleficence are the forerunners in the setting of physicians dealing with cases of suspected child abuse. The principle of beneficence in this context refers to the physician acting in the best interest of their patient (the child) and non-maleficence refers to physicians avoiding causing harm to their patients. While it seems simple, the legal and ethical obligations held by physicians with regards to child abuse is rather difficult and perplexed. In order to understand the challenges faced by many physicians with regards to reporting child abuse, abuse must first be identified.
Child abuse can be defined into four different categories, namely, emotional, sexual, physical abuse and neglect (Health Service Executive, 2011). Emotional abuse revolves around the relationship between child and carer and occurs when a child’s developmental needs are not met (Health Service Executive, 2011). Sexual abuse includes a sexual offence against a child, voluntary exposure of the child to pornography, or voluntary sexual activity while the child is present (Children First Act, 2015). Physical abuse can be defined as acts of a caregiver that cause actual physical harm or have the potential of harm (World Health Organization, 2002). Neglect is indicated by the failure of a parent with adequate resources to provide for the development of a child (World Health Organization, 2002).
As aforementioned, it is a physician’s duty to act in the best interest of their patients as well as avoiding causing them harm. In relation to children and according to law, if a physician “believe[s] or has reasonable grounds for suspecting that a child is being harmed, has been harmed, or is at risk of harm through sexual, physical emotional abuse or neglect…” the physician must report this to the proper authorities without pause, as the welfare of the child is of utmost significance (Medical Council of Ireland, 2016). In these cases, the parents/guardians of the child in question should be informed of the physician’s request to report their worries, unless doing so may further endanger the child (Medical Council of Ireland, 2016). Though reporting their findings would be a breach in confidentiality of their patient, protection of the child is justifiable in the eyes of the law as long as there are reasonable grounds that acts of abuse have been committed against a child (Medical Council of Ireland, 2016). Similarly, physicians who report cases of child abuse who believe what they suspect is true and are acting in the best interest of the child cannot be prosecuted for making false reports (Protection For Persons Reporting Child Abuse Act, 1998).
Upon reflection, this law seems to fall within a very grey area. While physicians must practice within the full extent of the law, it is without question that a physician who suspects probable cause beyond a reasonable doubt that a child may be a victim or become a victim of abuse must report their findings to the Health Services Executive. However, where is the line drawn of what constitutes “reasonable grounds?” The way the law is written implies a level of subjectivity among practitioners. Of course every case is different and it is the decision of the physician to pursue further action if they so choose; however, the means by which they form their conclusion may be unclear or uncertain. Moreover, a physician reporting a case of child abuse to the authorities is indeed following their moral compass and acting on their principle of beneficence, but at the same time may be impinging on non-maleficence. If there was an inquisition of child abuse with probable cause that ended up to be false, they may be protected from litigation, but may have breached their ethical duty of non-maleficence, where harm and embarrassment are brought to the family dynamic. The law seems to be written specifically to avoid turning a blind eye towards child abuse as this may lead to criminal prosecution, where physicians who do suspect abuse are protected even though their qualms may be false.
Apart from the legal and ethical aspects physicians must be wary of, there are several other challenges that physicians face when dealing with child abuse cases. Many physicians feel as though their knowledge on the subject of child abuse is insufficient and this may impact the timeframe of reporting abuse. Many feel as though more convincing evidence is required before a report is filed, but if a child is indeed being abused, this will allow it to perpetuate causing more violence (Bannwart & de Faria Brino, 2011). This in turn with possibly inadequate training on how to deal with victims of abuse may contribute to a physician’s decision on whether to report child abuse. Physicians fear that reporting potential child abuse may lead to damaging a family’s dynamics, but more so their involvement in legal matters or receiving backlash from the family (Bannwart & de Faria Bruno, 2011). Similarly, some physicians may find it difficult to recognize emotional abuse and neglect, unlike physical abuse which leaves visible damage (Bannwart & de Faria Brino, 2011).
In order to minimize the challenges that physicians face regarding victims of child abuse, physicians should be better educated about abuse and given the tools necessary for early recognition and reporting their findings. Early reporting of abuse is vital as it is a means to fight violence since it promotes the employment of intervention strategies at different levels. These tools will allow physicians to develop the skills and capacities necessary to identify situations of abuse, diminish their fear of reporting abuse, and protecting the affected child/adolescent. New strategies coincided with the law, will allow the physician to act in the best interest of their as the safety of their patients is of greatest importance.
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