Doctor and Society

Doctor and Society
Physicians are mandatory reporters of child abuse. This means that the physician has a
duty to report child abuse even if they feel uncomfortable doing so. There is no discretion on
whether or not to report abuse. In addition, even suspected child abuse must be reported. The
reporting to child protective services should happen immediately so that there can be an
urgent intervention to prevent further abuse.
For example, a 20-year-old woman brings her seven-year-old son into the
emergency department for a broken arm. The child has been to the emergency
department twice before for various injuries. The mother lives with her boyfriend who
is not the child’s father. You have no direct proof that abuse has occurred and the
mother simply states that the child is accident prone. When you ask her whether her
domestic partner may be injuring the child she becomes very angry and vigorously
denies it. What should you do?
Report suspected child abuse cases no matter what the family says. The child abuse laws
are very specific in terms of protecting the mandatory reporter against liability. Even if there
is no abuse found, the suspected abuser has no standing to file suit against you as long as you
make the report in good faith. In other words, as long as you are sincerely and honestly
making the report there is no liability on your end. Although physicians are mandatory
reporters, anyone who has a good reason to suspect child abuse can make a report as long as
the same criteria are operating. You must have a reason to suspect the abuse and there must
be no element of trying to harm or embarrass the family.
The same criteria described for child abuse generally apply to elder abuse. Instead of
child protective services, there are adult protective services. Reports made in good faith can
be done without liability to the reporter. The circumstances with elder abuse are less clear
than with child abuse, because the elderly person is often a still-competent adult who may
object to the report of the abuse on the basis that they are afraid of repercussions in the home
or the loss of the home. Nevertheless, you must report elder abuse, and partially breaching
the confidentiality of the patient and family is permissible in the interest of protecting a
vulnerable person.
The other reason that elder abuse reporting is less clear is that there is no uniform
national standard for it in all 50 states. The vast majority of states, however, have a reporting
system similar to that for reporting child abuse. The bottom line for USMLE is that you
should answer to “report the abuse to adult protective services” if the case is presented.
The rules on reporting impaired drivers vary enormously nationally. There is no other
aspect of medical ethics and health-care legality that has such state-to-state variability as the
management of the impaired driver. All states require the patient to report seizure disorders;
however the period of time that the driver must stay off the road varies vastly from one state
to another and therefore cannot be tested on the USMLE.
Physicians cannot suspend driving privileges. Only the state-sponsored Department of
Motor Vehicles (DMV) can suspend or revoke driving privileges. When a driver is impaired
in any way, the first step is to encourage the driver to report the impairment, to the DMV. In
addition, the physician should encourage all impaired drivers to limit or curtail their driving.
There is no uniform agreement of what, beside seizure disorders and visual impairment
should be reported in all states. Only a few states have specific laws requiring reporting of
syncopal episodes. Not all states offer immunity to physicians, such as the protections
offered for reporting child abuse, for reporting an impaired driver.
For example, you are the attending physician on a patient admitted to the hospital
with a first-time seizure. The head CT and EEG are normal. You will not be starting
antiseizure medications. The patient drives to work regularly. What should you do
concerning the patient’s ability to drive?
Mandatory self-reporting of seizures is required in all 50 states. If there is an answer that
says “encourage refraining from driving” or “counsel on alternate forms of transportation,”
that is the best thing to do first. If that is not one of the answers then choose “recommend the
patient inform the DMV” is the best choice.
For example, you are evaluating an 87-year-old man in your office for markedly
worsening cognitive dysfunction. He is on a number of cardiac medications as well that
leave him somewhat dizzy. There is evidence of psychomotor retardation and delayed
reaction time on your examination. You are concerned that the patient regularly drives.
What should you do about his driving?
If the patient does not have a specific disease such as a seizure disorder that makes him
potentially unsafe, then it is much less clear what your responsibilities are toward both the
patient as well as to society. In cases like this the best answer is to recommend that the
patient with cognitive problems curtail his driving or find alternate forms of transportation.
Given that the reporting requirements are so variable on a state-to-state basis this is often the
best answer that would be uniformly true in all states.
For example, you have a 65-year-old man with progressive glaucoma in your
office. His vision is severely impaired and getting worse. You strongly doubt that he
can read traffic signs on the highway. You have repeatedly encouraged him to curtail
his driving but he has not. What is your responsibility toward this patient?
In those cases where the patient’s visual acuity is so severely impaired that you suspect he
is a danger to himself and to others when driving, you must strongly encourage the patient to
stop driving. You can intervene directly in the states that require intact vision for
recertification of the driver’s license by refusing to provide recertification. In those cases
where this is not possible you must inform the patient that it is your duty to notify the DMV
of his impairment. You do not have the right to remove or suspend driving privileges. You
do, however, have a duty to report a visually impaired driver to the DMV so that the DMV
may make its own determination of whether the patient’s license should be removed or
A physician can not ethically participate in executions in prisons. This is true even
though the execution is legal in that state. Participating as a physician in any way in an
execution directly opposes the ethical imperative to preserve life. The physician’s ethical duty
to relieve suffering and to protect life supersedes any ability to participate in the execution.
For example, you are a physician in a state prison. The warden has asked your
assistance in checking the apparatus that delivers a lethal injection scheduled for use in
an execution tomorrow. He is not asking you to administer the injection. You have
never met the patient before and you have no prior doctor/patient relationship with the
condemned prisoner. What should you tell the warden?
A physician cannot participate in any way in an execution as a physician. Participating in
an execution impairs your physician/patient relationships with the other prisoners who are
your patients. It is ethically impermissible to participate even at the level of a technical
consultant—even if you have no doctor/patient relationship with the prisoner. You may not
give the injection, start the IV line, mix the medications for injection, or design the
formulation for the lethal injection. It is not even permissible for you to certify that death has
occurred unless another party has determined it first.
Physicians cannot participate in torture at any level. The knowledge of torture must be
reported and opposed as you would report and oppose elder abuse, child abuse, or an
impaired driver. You may treat those injured by torture once the victims have been removed
from an environment where torture may occur; you cannot treat injuries to allow patients to
become well enough to withstand more torture.
The ethics and legalities surrounding spousal abuse are somewhat different from those for
child abuse and elder abuse. In the case of spousal abuse, you are dealing with an adult
patient that is generally competent consequently you do not have the same authority to report
the abuse against the wishes of the victim as you would in a case of child abuse. Many
victims experiencing spousal abuse believe they are not in a position to be able to leave the
relationship or to report the abuse for fear of worse abuse. Consequently you cannot report
the abuse to the police or to anyone else without the express consent of the victim.
For example, a 45-year-old woman comes to the emergency department after
having had her nose broken by her husband. She has been abused several times in the
past. When you tell her you will report the injury to the police she becomes very
anxious and insists you tell no one because her husband is a police officer. What should
you do?
When the patient will not give consent to have the injury reported, you should answer
that you will “encourage the victim to report” or “offer counseling.”
Reporting of gunshot wounds is mandatory but from a different perspective than the other
forms of reporting. The mandatory reporting of gunshot wounds is based on pursuing a
criminal investigation of the person doing the shooting. Report a gunshot wound even if the
victim objects. The societal need for safety supersedes the privacy of the patient in the case
of gunshots.
Gifts from industry are to be limited in both type and by numerical monetary value. The
presumption is that all gifts from industry are an indirect, attempt to obtain influence from
physicians in terms of their prescribing patterns. Modest gifts of less than $100 in value are
acceptable only if they are medical or educational in nature. In other words, you can receive
$100 worth of books or medical equipment but you cannot just get a $100 check for cash. In
addition, the industry may sponsor educational presentations as long as they do not interfere
with the content. Physicians may accept meals that are in association with educational
experiences such as lectures or conferences.
Physicians are prohibited from accepting gifts from the industry that are purely geared to
enhance the income of the physician or merely for entertainment. For example, the physician
cannot accept tickets to basketball games or other sporting events, theater tickets, ski trips, or
gift certificates to department stores.