Ethical Case Discussion with the 4 year medical students
of introductory clinical medicine course, 2000



Case 3)
The patient is a 3-year-old girl.

The patient's father took his daughter to an emergency room for her right
arm's pain. He said the daughter fell down and hit her hand through an
accident.

From X-ray examination on her hand, right radial bone fracture was
pointed out. But from the physical examination, there are many bruises
in her whole body. And the patient was awfully afraid of her father.
So the doctor in charge thought it is not only an accident but child-abuse
should be suspected.

(Question)
If you were a doctor in charge of this emergency room, what do
you do to this patient and to her father?



Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life Sciences,
Michigan State University, East Lansing, MI USA.

Suspected child abuse (Japanese case) / Social Aspects of Care

The development of social policy regarding child abuse and neglect, including the
passage of laws, has made this a fairly simple issue to address in U.S. medical practice.
Assuming that the injury is more serious than could be explained by the account of the
trauma given by the father; and the existence of previous bruises; and the behavioral
evidence of the child's apparent fear; there are many indicators of possible child abuse.
By law the U.S. physician must now report this case to the legal authorities, and is
entitled if necessary to hospitalize the patient to provide a safe environment while the
child protective service investigation is then pursued. The physician in my view should
openly state to the father that he/she is obligated in such cases to report, and is not
making any judgment of actual child abuse, only reporting the suspicion. This may allow
the physician to remain an ally of the father and family rather than being forced into an
adversarial role. At least some abusive parents wish they could get help for their
abusive behavior and are actually relieved to be found out in this way, if the services
offered are supportive and helpful toward the parent, rather than punative.

I can report an unfortunate trend in child protective services in my midwestern US city.
When I began to practice here in 1980 we had a model system of child protective
services. It was understood that abusive parents suffered themselves, and were often
themselves victims of abuse as children; so they were seen as worthy of help rather
than as criminals. There were well-staffed programs so that an early report of potential
abuse would often lead to an intervention which helped the parents to better cope with
stress, and so prevented future abuse and allowed the child to remain in the home.

Then over the years, services were gradually discontinued or reduced as government
spending was cut, leaving the child agencies very short staffed. Now, a report of
suspected child abuse often leads to a very superficial investigation, almost no real help
for the parents, and an adversarial atmosphere. It is seldom possible for parents to get
real help from the agency, so either the case is judged to be mild and the child goes
back to the same home environment with all its problems; or the case is judged to be
major and the child is removed from the home.

While I remain obligated by law to report ANY suspicion of child abuse or neglect, I
admit to being reluctant now to report very vague suspicions. The case described here
however sounds like a serious case and would require reporting in any event.



Tom Tomlinson
Michigan State University

I will add to Dr. Brody's excellent comments that US child abuse policies provide an
perfect example of how the very best intentions can produce unintended and
undesirable side effects. The problem with child abuse reporting prior to the mid-70's
was that there was too little of it. Many physicians did not report, even in the most
obvious cases like the one described by Dr. Shirahama. And so the law was changed
so that physicians (and many other professionals, like teachers) were legally obligated
to report any suspicion. All the legal cards were deliberately stacked in favor of
reporting the merest suspicion. If a physician reported a case that turned out not to
be child abuse at all, he was shielded from any legal consequences. But if he failed to
report even the merest suspicion which later turned out to be child abuse, he was
subject to both criminal and civil penalties. The result has been an explosion of
reporting, overwhelming the resources for investigating and intervening effectively in
child abuse cases. Most reported cases in the US-- 56%-- turn out to be
"unsubstantiated" (whether this means they could not be adequately investigated, or
means that they weren't really child abuse is a matter of controversy); and there have
been several widely reported cases of false allegations which had severe
consequences for those wrongly accused and the children involved. And so the
combination of the legal requirements and the inadequate resources creates the
ethical problem Dr. Brody refers to. On the one hand, the physician feels obligated to
obey the law; but on the other, he may be rightly worried about what can happen to a
family he reports once they are taken into the child protection system.



If you kindly send your comments on this case, please send it to the
following mail adress.

mailto:HQC00330@nifty.ne.jp

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Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic
Clinical Professor, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan
mailto:HQC00330@nifty.ne.jp