The moral question that arises from the above-mentioned case is as follows: Should I call Child Protective Services (CPS) to report the mother for child abuse? The relevant information of this case includes:
- I am the general practitioner,
- the alleged mother is the primary caretaker,
- the mother brings her child in to the medical office for flu-like symptoms,
- when the boy removes his shirt, I notice a pattern of bruises on the boy’s torso,
- the mother tells me that the bruises are from “cao gio,” which is a practice of rubbing warm oils/gels to raise out bad blood and improve circulation/healing (this practice is also called “coining”), and
- the boy winces in pain upon palpation of the bruises with a stethoscope.
Additionally, the stakeholders involved in this case include:
- the mother,
- the child (patient),
- myself (Physician Assistant),
- the child’s family,
- Child Protective Services if they are involved, and
- the office that I work at.
- There are also some questions that would need to be answered which would play a role in analyzing the case.
First of all, it would be important to know the age of the child. This would be significant because the age and maturity of the child would determine if I could speak to the child privately without his mother. It would be more difficult for the child to understand the depth and details of what was truly causing the bruises if the child were younger. Secondly, I would be interested in knowing what type of clothes the child was wearing to the appointment and the description of the bruises. If the child was wearing clothes that were inappropriate for the weather, I would be more suspicious for child abuse because the child could be wearing conservative clothing to purposely hide his bruises. Furthermore, the color of the bruises could help determine how old the bruises are, and the size could potentially help to narrow down the source of the bruises. It would also be important to determine the cultural and religious background of the patient and his mother, the involvement of the mother and her partner in her child’s life, and whether or not there are other children in the family. If the patient’s cultural and religious background support cao gio, regardless of the pain elicited from the practice, it would be more difficult for me, a healthcare provider, to explain to the mother that some cultural practices are more harmful than beneficial.
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The relationship and involvement of the mother and her partner in the child’s life would help me to determine if there is also a case of negligence occurring along with child abuse as well. If there are other children in this family, and child abuse is suspected, I would possibly need to include this information in my report to CPS. Finally, I would need to know the past medical history of the child and also some details about the psychosocial history of the mother. If the child is more prone to blood disorders, it would affect whether or not I would approach CPS. If the mother had any blood disorders, the cause of the bruises could be from a hereditary disorder, not from cao gio. If the mother had a mental illness or revealed signs of significant stress, it would be another factor that could help to determine whether or not child abuse is truly occurring. Available Options and consequences: My first option would be to report the mother to CPS after explaining the risks, because I believed it was child abuse. However, as a consequence of doing so, the mother might feel disrespected and humiliated because she was telling the truth, and because I took away her autonomy. She could also lose custody of her child if CPS found that she was a harm to her child.
Additionally, if the child had any more interactions with his mother, and the mother was truly abusing her child, she could become aggravated and abuse him more. My second option would be to not report the mother to CPS after explaining the risks, because I did not believe it was child abuse. Consequently, the mother could be abusing her child, and the child’s life may be in danger. There may also be a chance that it was not child abuse, and if I did not report them to CPS, the family would not go through additional stress. My third option would be to find out more information in the next few encounters and wait to decide on whether or not to report to CPS. With this option, the mother might continue to abuse her child, leading to the deterioration of the child’s health. By learning more about this situation, I could communicate with the mother to explain that it is hurting her child more than helping him.
Evaluation of each option: As mentioned above, there are three possible options for evaluating this scenario. The three options that I, as a Physician Assistant, would choose are summarized as follows:
- Reporting the mother immediately to Child Protective Services (CPS) because I believe that she is abusing her child,
- There is no need to report the mother to CPS because I do not believe it is child abuse, or
- would find out more information about the mother and the practices she takes part in before deciding on whether or not to report her to CPS.
If I were to report the mother to CPS, the child (and any of his siblings) could be taken away from their family and be placed in a foster home. Furthermore, the children could also be separated from each other. This would create significant emotional instability and trauma both to the parents and to the children. However, as a healthcare provider, I would be doing what I believe was best for my patient by removing him from a toxic environment, thus practicing beneficence. Beneficence, in particular, is doing what is best for the patient. It is “a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs.”1 In addition, I would be involving career professionals specializing in the appropriate fields to take a lead in the best course of action. If I did not report the mother to CPS, I essentially would not be doing what is best for my patient because the patient could still be under the threat of being harmed or abused.
Thus, I would be forfeiting the concept of beneficence. In contrast, I would not be putting the child, his mother, and the rest of his family through emotional turmoil. By not interfering, I would also not be deciding how the mother chooses to take care of her child, which would allow her to still be autonomous. Autonomy is defined as a “norm of respecting and supporting independent decisions.”1 Lastly, if I were to find out more information in the next few interactions prior to making a decision on CPS, I could potentially be putting the child at a higher risk. The mother could decide to find another provider after realizing that I would be inquiring extensively about the bruises and practices of cao gio.
She could also completely stop going to healthcare providers to avoid getting caught if she truly were abusing her child. Regardless of whether or not she was taking part in abusing her child, her trust in the healthcare system and medical providers may also suffer. However, by waiting to decide on whether or not to report this mother to CPS, I would not be taking any steps to drastically change the child’s life. Chosen Option and Argument: [1] After explaining the risks, I would choose to report the mother to CPS because I believe she is abusing her child. In Section 63.2-100 of the Code of Virginia, child abuse is defined as “any child under 18 years of age whose parent or any person responsible for his or her care causes or threatens to cause a non-accidental physical or mental injury”
In addition, this Code defines physical abuse as “any act which, regardless of intent, results in a non-accidental physical injury”. The definition also specifically includes that the intent does not determine whether or not an action is considered abuse. Thus, even if the mother had a positive intent to ultimately heal her child, I would still need to question why she was not able to notice that the practice of cao gio was causing her child injuries and pain. Bruises that are typically seen in hidden areas, such as torsos, armpits, and/or buttocks, are an alarming sign for potential child abuse.3 When the boy in this scenario removed his shirt, I noticed various bruises specifically on his torso, which could be a sign of possible abuse. Not only did I notice the bruises, but I also noticed that the child winced in pain, meaning that the situation which led to the bruises was a fairly recent, painful affair.
My training as a healthcare provider helps me to evaluate and diagnose medical conditions and provide preventative medical care through conducting a proper history and physical exam, performing diagnostic tests, and providing the proper treatment. In this particular case, it would not be enough to only evaluate and treat what the child primarily visited the medical office for (i.e perform a flu swab and supply the child with Tamiflu to reduce the severity of the flu itself). Upon determining the extent of the bruises, child abuse is high on the differential diagnosis (a list of possible conditions that could cause bruises). Other medical diagnoses, including various blood disorders, could also be on the list of differential diagnoses.
After performing proper diagnostics and ruling in that child abuse is highest on the differential, the “treatment” would be to try to address the core reason for the bruises, so that they are not recurring incidences. Thus, the child would be protected from further harm, and the physical, emotional, and mental well-being of my patient would improve in the long run. According to the Physician Assistant Code of Conduct, I am to “recognize and understand my professional and personal limitations.”
Although I may be trained in evaluating the symptoms of physical abuse, I am not adequately trained to evaluate what caused the bruises and how to actually prevent abuse. In addition, Physician Assistants abide to four main bioethical principles:
- autonomy,
- beneficence,
- non-maleficence, and
- justice
Beneficence, as mentioned before, is doing what is best for the patient. If the child presented with extensive bruises and the mother did not understand the risks of coining, it would be best to report this case to CPS. It is my professional and moral responsibility as a Physician Assistant to put the physical, mental, and emotional health of my patient first. To do so, I would need to take whatever steps necessary to prevent further harm from reaching my patient (the boy, in this case), thus following the bioethical principle of beneficence, by turning to resources that are specialized to evaluate such scenarios (i.e. CPS). Additionally, the cultural and religious background of the family, along with their immigration status, would make a significant difference on how the child perceives the practice of cao gio. Acculturation is defined as “the process of sociocultural transition whereby immigrants and refugees make decisions about the degree to which they will retain and relinquish indigenous cultural tenets in favor of adopting the idioms of the host society.” If the child was born and raised in the United States or had enough time to interact with his peers, there is the possibility that he might not hold the same importance to cao gio as his family does. In fact, he may view cao gio as a harmful practice, rather than one that is beneficial, if he finds that many other American families do not participate in such techniques.
Therefore, it would be of utmost importance to get the child’s opinion on these practices without the interference of his family members. However, some providers may counter that approaching CPS is making a mountain out of a molehill. Instead of taking such drastic measures, they could argue that there could be other reasons for the child to flinch away from my stethoscope, including various behavioral disorders. Furthermore, if I were to immediately report the mother to CPS, the situation could escalate into one where the child and any possible siblings could be taken away from his or their family and could be placed in a foster care.
Thus, I would be forfeiting the bioethical principle of non-maleficence. Non-maleficence is defined as “a norm of avoiding the causation of harm.”1 By deliberately involving CPS and causing potential emotional disturbances from the investigation, some could argue that I would be doing more harm than good. Furthermore, if the child is at an age where he cannot understand what is actually going on, other healthcare providers may argue that this instability may actually exacerbate or create lifelong emotional and behavioral disturbances. Other providers could argue that even after conducting a thorough evaluation, CPS may determine that there is no reason for the child and his possible siblings to be separated and taken to foster care. This thorough investigation would still create emotional turmoil in the family’s life, creating resentment towards healthcare professionals simply because there was a lack of trust between provider and patient. In addition, the mother could counter that I would be taking away her autonomy if I were to immediately involve CPS.
She may argue that her religious and cultural values were disrespected because I was not able to accept the practice of cao gio, and instead was distrustful of her and contacted CPS. By taking away her autonomy, the mother might feel maleficent towards all healthcare providers. An argument for the above-mentioned counter would be that although there would be some negative repercussions with reporting the mother, it would still be better to approach professionals, such as CPS, who are trained to evaluate, analyze, and handle such situations to make sure the abuse is not the cause for the bruises. Sometimes, a bold action must be taken for the betterment of the patient. For example, chemotherapy has severe side effects and can frequently disrupt the quality of a patient’s life while being treated.
However, the ultimate goal is to rid the human body of malignant cancer cells to eventually become a healthier human being. Similarly, in this case, it would be for the betterment of the patient and his family to go through some temporary discomfort of a CPS investigation to have a positive end outcome. Once a CPS investigation is completed, there could be two outcomes: The mother of the patient did not perform any acts of physical abuse, or the mother of the patient did, in fact, physically abuse her child. If the mother did not abuse her child, I would be able to further fulfill my moral responsibility of beneficence by continuing to communicate with the mother about the risks of coining and how other preventative care measures are more helpful. If the mother did physically abuse her child, this child would now be taken care of in two different ways: legally and emotionally through CPS, and medically by myself, without any negative interference from his family. My professional and moral responsibilities include making independent decisions to do what is best for my patient. I am not required to support harmful and painful practices. CPS has the expertise to evaluate the situation and provide the proper treatments with the child’s best interest at hand, and I would serve as the bridge between potential child abuse and CPS. The negative repercussions are a small price to pay to prevent future harm, and for that reason, I would choose to involve Child Protective Services in this scenario. In the first paragraph of the chosen option/argument, I would write out the main points/reasons why you favor this option. Then, in the following couple of paragraphs, you can expand this!
