Time to Make a Call? The Ethics of Mandatory Reporting

Over 50 years ago, the first U.S. laws were passed regarding the mandatory reporting of suspected child abuse and neglect. During the ensuing decades, other laws have emerged that delineate the role of the physician in protecting his or her patients as well as the public. In theory, the reporting by clinicians who become aware of concerns plays a critical role in decreasing harms; however, in practice, various tensions exist, including the limits of our observations, the veracity of information received, and perhaps an underlying ambivalence about privacy and the role of the doctor. This column grapples with the ethical issues of mandatory reporting. Why might we be reluctant to report suspected abuse or neglect, someone who is unsafe to drive, or a colleague who is impaired? At the core of the concerns about reporting is the relationship—that between doctor and patient, doctor and family members, and between colleagues. Many also express distrust in systems or worry about what will be done with the information that is provided to the authorities. In the first essay, Rebecca Brashler, LCSW, Director of Global Patient Services at the Rehabilitation Institute of Chicago and a colleague in the Rehabilitation Institute of Chicago's Donnelley Ethics Program, discusses the challenges in reporting child abuse or neglect. The second essay by Hillel Finestone, MD, and his colleagues from Ottawa, Ontario, Canada, addresses the reporting of impaired drivers and suggests that it should become mandatory in more places. Dr. Finestone is a physiatrist, Associate Professor at the University of Ottawa, Director of Stroke Rehabilitation Research at Élisabeth Bruyère Hospital, Bruyère Continuing Care, and an associate editor of the journal PM&R. He reached out to me to consider the topic of mandatory reporting of impaired drivers for an ethics/legal column, and I used his idea as a catalyst to think more broadly about reporting in general. The final essay is by Marie Bismark, MD, a public health physician and health lawyer, who leads the Law and Public Health Group at the University of Melbourne School of Population and Global Health in Melbourne, Australia. She has published several articles on the impact of a law in Australia that mandates reporting of impaired physicians. This column raises specific issues about each type of reporting but engages more general aspects as well. Clinicians are left balancing the ethical principles of nonmaleficence and justice, working with imperfect systems, and trying to meet their obligations, both legally and ethically. As always, I welcome comments and ideas for future columns at [email protected]. Rehabilitation Institute of Chicago and Northwestern University Feinberg School of Medicine Good faith is an abstract and comprehensive term that encompasses a sincere belief or motive without any malice or the desire to defraud others. It derives from the translation of the Latin term bona fide, and courts use the two terms interchangeably 1. Mandated reporting of suspected child abuse by physicians is accepted widely despite the inherent challenges. Ethically, the idea that “parental liberty should not be unduly privileged over children's rights to personal security” 2 seems easy to justify. There remain, however many reasons why a compassionate and well-trained physician may hesitate to make a hotline call to their State Protective Services Department—including uncertainty about the presence of abuse, disbelief that the parents are capable of inflicting injury, concern that reporting will tarnish their trusting relationship with the parents, and worries that involving the courts/state agencies could make matters worse, resulting from the creation of an adversarial relationship or our flawed foster care system. In my experience, it is the lack of certainty that creates the most angst. Rarely do we actually witness an evil, malicious adult in the act of intentionally harming a child where the evidence is clear and our knowledge about the incident is irrefutable. Usually we end up piecing together bits of evidence—some of which may come to us second- or thirdhand—most of which is inconclusive but troubling. Ultimately, we must rely on our “gut” sense of what may have taken place. The physicians I know take mandated reporting very seriously—particularly physiatrists who appreciate that disabled children are at a greater risk for abuse than their able bodied peers 3. They participate in training courses and annual hospital competencies to review common characteristics of abuse in the hope of differentiating accidental injuries from those inflicted by others. They consult with colleagues when uncertain about when to file a report, and they provide a thorough hospital examination of any child who may need protection. On rare occasions, they may even step up to provide protective custody themselves when they believe a state agency is not acting adequately to protect a child in their jurisdiction; however, being 100% certain about the cause of a child's injuries is rare. In medicine, we think about false positives and false negatives when discussing test results and diagnostic investigations. That language, although rarely used in protective services, might help physicians grapple with the uncertainties that surround abuse reporting. As a former protective services worker, the cases where I was wrong will always haunt me … The 5-year-old girl I saw at her after-school program had textbook signs of abuse—she was covered with multiple deep bruises in various stages of healing on areas of her body that could not have possibly been from an accidental fall. She offered no plausible explanation for the cause of her bruises but quietly sobbed throughout the interview. Her teachers described her as increasingly listless and withdrawn. She was significantly underweight for her age/height. After careful examination by an emergency room physician, her parents were interviewed separately. The child's mother was also at a loss to explain the bruising but confirmed that her husband believed in “strict discipline” and was often alone with their children when she worked at night. When asked if she thought her husband could have inflicted these injuries the mother stated that she “wasn't sure.” The child's father was defensive and extremely difficult to interview. He angrily and adamantly defended his right to discipline his children as he saw fit. As a recent immigrant to the United States, he was astounded that the state had any authority to interfere. The young child and her infant brother were placed in a temporary foster care home for protection that night. However, before charges were filed and the investigation completed, medical tests returned indicating that the child had porphyria, which explained both her bruising and her failure to thrive. Unfortunately, the children and parents had already been traumatized by the system that was meant to safeguard them. Furthermore, the parents’ trust in each other, in the school system, and in the health care establishment had been irreparably damaged. I met a brawny and gregarious 14-year-old teenager in an inner-city health clinic where he was being treated for a broken nose and facial lacerations. A nurse raised concerns because he had been coming in frequently with various injuries and he was never accompanied by a parent. When interviewed, the teen joked about being “clumsy” and dismissed any suggestion that anyone was hurting him. The physician verified that the injuries that were being addressed that day, as well as his prior injuries, could easily be the result of accidents. A quick call to the school did not reveal any concerns about educational performance or changes in behavior. His single mother was working 3 jobs to help support her children yet readily scheduled an interview for the following morning. But that night when the teen arrived home and reported being treated for his injuries and talking to a social worker who was going to conduct a home visit, an uncle who lived with the family beat the young man brutally with a pipe as punishment. The child ended up in the ICU with intracranial bleeding less than 24 hours after the initial hotline call. The system is not perfect. In these cases, well-meaning mandated reporters performed their duties admirably but neither ended with an acceptable outcome. It is the knowledge that not acting can lead to disaster but overreacting can be equally devastating that makes mandated reporting so challenging. The fact that it remains a high-risk responsibility fraught with possible false positives and false negatives is why I feel strongly that when making a hotline call, I disclose my concerns directly to the parents. We are mandated to call the hotline when we suspect abuse/neglect, but we are NOT mandated to notify the parents or suspected abusers of our actions. Many find this provision comforting, but the anonymous call option seems like a cop out. I find that if I disclose my concerns and inform caregivers that I am legally obligated to call the hotline, I also gain an opportunity to let them know that I am acting in good faith. I have no malice or secondary agenda. I'm fulfilling my obligation to protect a vulnerable patient on the basis of uncertain data and my best judgment. I admit that I might be wrong and I apologize up front in case my actions cause any unintended harm. I let them know that I hope the call will lead to more open communication, additional social supports in the home, counseling, and a safety net for the child. This disclosure and explanation are not mandated but they can be therapeutic—both for the child's caregiver and for the uncertain health care provider. It also normalizes the call by putting it into the same context as other imperfect medical tests or procedures we “order,” none of which are without risk or guaranteed to result in ideal outcomes. University of Ottawa and Élisabeth Bruyère Hospital, Bruyère Continuing Care Colleen Nevison Ottawa Hospital Research Institute, The Ottawa Hospital Shawn C. Marshall, MD, MSc, FRCPC University of Ottawa and The Ottawa Hospital Rehabilitation Centre George Deng, MD University of Manitoba Physicians, particularly physiatrists, often are responsible for assessing factors that influence their patients’ ability to drive; however, reporting patients who may be unsafe to drive to licensing authorities is complicated. A balance must be found between maintaining patients’ autonomy while ensuring the safety of all road users. The following case illustrates the complex issues involved in physician reporting. Mrs. K. is a 78-year-old woman with hypertension. She presented to the emergency department with right primarily motor hemiparesis; a left lacunar infarct was noted in the internal capsule on magnetic resonance imaging. She also was noted to have mild-to-moderate microangiopathy. You see her in your stroke rehabilitation clinic 3 weeks later. She had been an inpatient on the acute care neurology service for 3 days, where she was told that her hypertension needed “better treatment.” Her walking is much improved. Her husband said that she was having “slight” trouble organizing breakfast. She used to be an expert baker but now had trouble following recipes. He also stated that during the past year she hadn't been as “sharp” as she used to be. Her Montreal Cognitive Assessment score is 25 (normal ≥26). On the clock drawing test, she omits a few numbers on the left. You think about driving. You know that some jurisdictions obligate physicians to report patients who have any type of medical condition that may make it dangerous for them to drive. Mrs. K. believes that she should resume driving immediately. Her husband states that “she only drives around the block anyway.” What do you do? Do you write a letter to the licensing authority? A black-and-white division of safe and at-risk patients does not exist. Careful reflection and analysis are required to make the best decision for the patient, the state, and the safety of others on the road. In the clinic or office, there are many nuances that play into the decision to report a patient. What effect will the decision have on the physician−patient relationship? What are physicians’ legal requirements for the mandatory reporting of unsafe drivers, and how do they vary in different jurisdictions? What legal action might the patient take? Finally, how can physicians be fully confident in their decision? Each difficulty presents a potential roadblock in the decision-making process. Physicians are concerned that reporting medically unfit drivers may harm the physician–patient relationship 1. Redelmeier et al 2 identified consecutive patients in Ontario who had received a “medical warning” from a physician between April 1, 2006, and December 31, 2009. (Note, the physicians were not simply warning their patients in an office interview—they were reporting to the licensing authority patients who were medically unfit to drive). They examined the patients’ visits to their physician before and after reporting and found that, in the year after reporting, 29% of patients had a reduction in visits to the physician responsible, including 10% with 0 visits despite 2 or more visits in the previous year. This discontinuity in care requires further investigation, and research efforts should be focused on ways to maintain a healthy physician–patient relationship. Discussing fitness to drive early on in the relationship may help avoid damage later. The use of discussion aids or dialogues could help physicians communicate more effectively. Physicians face legal responsibilities and concerns surrounding their decision to report patients to licensing authorities. Currently, 7 Canadian provinces (British Columbia, Saskatchewan, Manitoba, Ontario, New Brunswick, Prince Edward Island, and Newfoundland and Labrador) and all 3 territories require the reporting of drivers who may be unfit to drive; Alberta, Quebec, and Nova Scotia permit the reporting of unsafe drivers but do not require it. Only 6 U.S. states (California, New and 6 of the in the and state and in Australia require reporting. Physicians may be concerned that a patient may take legal a in physician–patient A in is for a of and could be In the Canadian provinces and territories in which reporting of unfit drivers is physicians are from because these of patient information are required by The provinces without mandatory reporting provide legal protection of physicians who report their however, patient must be received before the patient is reported to the authorities. Do patients provide their physician with an of their and It seems physiatrists may be focused on the legal of reporting, a may be what if they not to The to and that, in if a physician to report an at-risk can be for by the patient should an 3. The physician could also be for patient and 3. Physicians require the support of their as well as protection to the safety of their patients and the general The Canadian a to physicians with assessing and patients regarding their fitness to drive. physicians feel for making about fitness to drive The lack of from licensing authorities regarding what and of need to be as well as medical training on the physicians in assessing fitness to drive In only of health care of were reported confident with to assessing fitness to drive After the to and of they for driving or with before In of Canadian family physicians that in this them and their patients medical and about assessing fitness to drive the of mandatory reporting by physicians’ in their and their decision-making of laws the reporting of unfit drivers, medically impaired patients et al 7 the impact of mandatory reporting of patients to the of of Only of the drivers who should have had their were The that, if the Canadian had been have been and up to or injuries could have been Redelmeier et al found that of Ontario drivers involved in a motor had of the being abuse, or of these drivers had a physician in the previous only had been reported to the licensing In a published in the New of those that reporting unsafe drivers is in the of motor drivers with medical patients who were reported to the of of Ontario, the of an emergency department during the the was the in the general with during the year after the report, a reduction of results provide support for mandatory reporting. In the Mrs. K. is in and and motor She could be unsafe to drive and could A law that mandates physician reporting her physician to report her to the licensing authorities. the physician could state that it was not his or her to report, the relationship not be it is to that patients should be responsible for their actions and their driving stroke is a and stroke to report themselves to driving authorities be In jurisdictions with mandatory reporting, or some patients with to driving. only a of patients’ at certain or in certain licensing a for drivers and the on physiatrists who are of the of mandatory reporting on the relationship and on their our driving ability is by or the is to report while with imperfect legal the need to and report patients who are unsafe to in the of the United States, and not a We for her in School of Population and Global University of Melbourne Physicians with a or other of health may a risk to their are that, at any of physicians may be impaired in their ability to provide safe the and risk will be identified by physician who is care to the impaired for a family physician may that a has or a use patient is a of medical to medical care and to issues however, is not an to might be to harm to or to the patient. in some physicians are required by law to report certain or of in many jurisdictions in to child abuse, and fitness to drive. is a specific for physicians to concerns about of their particularly the context of a relationship. however, have a on the of in health the of and the of and and the medical as that of who left a patient after the night have to about how physicians with health could be to for so 1. possible is to a legal on physicians to report impaired physicians in Australia have had a legal to notify the if they have a belief that physician, including their has the public at risk of harm in the of the because the has an In this the presence of any or or use that a health to his or her A physician who does not with this reporting may face reporting of impaired physicians has been that mandated reporting to protect patients from it may drive impaired physicians Careful analysis of the by and of the law that they do in fact common ethical that efforts to physician as as by impaired physicians and the risk to patients by impaired physicians. They however, on the of a legal these That the most is not about ethical issues is the right but about issues do we best In and of mandatory reporting have about a legal physicians’ to act with an ethical what does the of reporting impaired physicians from to what does the of a authority help to that impaired physicians does the net effect of these result in a health care system that is more or less safe for these is not an easy however, early research from Australia suggests that some of the by of mandatory reporting and some of the by are of the The that are received by the are of a and some physicians believe that the of a was in an impaired physician−patient into safe a mandatory reporting however, the of reporting of impaired physicians remains 3. some ethical of to colleagues and of the physician−patient relationship to even a legal to where are to be raised about the and of the some their to a report an impaired physician is on a sense of trust that the report will result in a and As the regarding impaired physicians there are 3 legal medical need not be or to be the critical is even an imperfect mandatory reporting be an over a system that on physicians’ for the reporting of impaired and are a basis for more research is needed to an of the potential and of mandatory reporting of impaired physicians. we do well to that as mandatory and will always require a internal to them

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.