The Thin Gray Line

The Thin Gray Line

The problem of child maltreatment is one of the largest social illnesses of our time reaching epidemic proportions, and current statistics may reflect only the surface of the predicament. Human service professionals including physicians, psychologists, social workers, teachers and psychiatrists are required to report known or suspected child abuse in every state of the union but that does not mean reporting is simple or without ramifications for the professional (Sonkin & Liebert, 1999; Armsworth, 1990).

The Law versus Ethics

Many states have mandates to report elder abuse, spouse abuse, child abuse and dangerous threats and behaviors. These legal requirements are mandatory and in several states a health care worker can be charged with a crime if they fail to report. However, ethical issues reflect standards of performance and practice that are usually identified by professional organizations that provide guidance to licensing bodies. Failure to adhere to those standards can result in loss of license and/or expulsion from a professional organization. Standard of practice is the minimal national criteria recognized among similar specialists, rather than a local community based standard (Liebert and Foster, 1994). This standard often becomes the yardstick used by ethics committees and licensing authorities to measure an appropriate course of action and standard of care. Common areas of obscurity include the handling of dual relationships, practicing within the scope of his or her competence and doctor-patient privilege and confidentiality. Either way, whether legal or ethical, laws and ethical standards are presumably set forth with the directive of "primum non nocere", do no harm anyone, thus reminding the health care worker of their responsibility to protect (Sonkin & Liebert, 1999).

In a perfect world legal, moral and ethical requirements of practice would be crystal clear all laid out in neat little rows with no doubts or confusion but the opposite seems to be the case. Not only are there inconsistencies between states but also within jurisdictions in the same state. Although reporting child abuse is a requirement in every state the standard can vary from reasonable suspicion to actually seeing the abused child before the person must report. Instances have also been recorded where child protective service workers in two different counties were given a specific set of circumstances, one worker filed a report and the other did not deem it necessary. Similar discrepancies with ethical issues have also been noted. So did the worker who did not file the report fail in his or her obligation to the child? Experience has shown us that not only are there differences in specific laws and ethical standards but there are also differences in their interpretation across individuals. Legal and ethical standards can appear confusing and open to interpretation guided by such parameters as the "unique aspects of the case", personal and professional experience, religious bias, and other such issues, yet statute and the theological basis underlying most ethics codes assume a decision rule based on a predictable outcome (Sonkin & Liebert, 1999).

Legal Issues

By far, the most common quandary faced by health care workers in reporting child abuse is the violation of patient privilege or confidentiality. Where does one draw the line? It can be quite puzzling especially since that statutory right to privacy also varies by jurisdiction. Based on wide spread ambiguity of the law and uncertainty on the part of health care workers, the findings of numerous studies have indicated that a significant number of clinicians have complied inconsistently with the legal mandate to report abuse (Pope & Bajt, 1988). The decision to report or not report is complex where the interests of the individual, the family, the profession and the community potentially come into conflict (Lippit, 1985). Although everyone agrees that child abuse is horrible, there are many disagreements as to what should be done to protect children who have been victimized and are at risk for more abuse. The fact that many health care workers do not report abuse despite the potential legal and ethical consequences is evidence that laws are not the complete solution to address this complex social phenomenon. It appears that a number of factors influence the reporting process. These factors include responsibility for the abuse, history of abuse(Zellman, 1990, 1992), recantation (Zellman, 1992), perception of the health care worker's role (Ansell & Ross, 1990; Fox 1984), type of abuse (Kalichman & Craig, 1991), socio-economic status of patient, license of held by the professional (Williams, Osborne & Rappaport, 1987) and years of practice (Barksdale, 1989). There are so many variables that affect a health care workers decision to report that it is not clear in any given situation which factors are working together to influence the outcome. One major criteria that should always be considered would be the greater the severity of the abuse and the younger the child, the sooner the report should be made. (Sonkin & Liebert, 1999).

In their review of the reporting literature, Brossig and Kalichman (1992) suggest a three part approach to decision making in reporting child abuse. They propose that legal factors, clinician characteristics, and situational factors seem to interact to influence whether or not a clinician chooses to report abuse.

Legal Factors. Common legal factors surrounding child abuse reporting decisions include: the health care workers knowledge of the child abuse laws, the wording of the law itself and the legal requirements of the law. Although reporting has increased since the passage of child abuse reporting laws studies indicate that, as a rule, clinicians' compliance with the law does not increase with increased knowledge of the law (Kalichman, Craig & Follingstad, 1989). However, some clinicians are more inclined to make informed decisions because of the importance of adhering to the law. For these individuals, knowledge of the reporting law does seem to facilitate reporting (Haas, Malouf & Mayerson, 1988; Brosig & Kalichman, 1992).

Similarly, the clarity of the specific child abuse statutes also affects the probability of reporting (Zellman, 1990). Laws that fail to adequately define child abuse and/or are unclear about the reporting procedure may impact the person's tendency to report or not. As previously noted, states that need only a "reasonable cause to believe" versus other states where the child must be physically brought to the health care