Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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REPORTING ABUSED PATIENTS

Morris Berman, O.D., M.S., AOA Ethics & Value Committee
Amy Falk, O.D., Associate Dean, MCPHS School of Optometry

Case Study #10

You enter the exam room and notice that your patient, a 10-year-old boy, has significant bruising around the right eye. You ask the boy, "tell me what happened to your eye," and he replies that he "fell off his bike." The patient is withdrawn and reluctant to provide additional details, and you begin to suspect that this may potentially be a case of child abuse. The patient is accompanied by a parent who will also be asked to provide information of circumstances that lead to the injury. As a doctor of optometry, what are your responsibilities to explore this further and to consider taking action?

The doctor's primary responsibility to the patient is to treat and manage the eye injury in the office or to make a referral for the condition, if needed. The doctor, however, should carefully and deliberately explore the circumstances that lead to the injury by also conversing with the parent. The answers to these questions will likely parallel the statements made by the young patient, but one should look for inconsistencies in the responses that may help you determine if child abuse might be suspected as the cause of the injury. You may want to probe the veracity of responses further by taking the patient to another examination room, explaining the need for "supplementary testing," without the parent. This may enable you to obtain a few more details leading to the injury to help determine whether or not this is a case of suspected child abuse. A note of caution will be to measure your inquiry to avoid adding to the distress of the child.

Child abuse laws exist on federal and state levels to keep children free from exploitation, harm and danger. The Child Abuse Prevention and Treatment Act (CAPTA)1, passed by the federal government in 1974, was reauthorized in 2010 and is the largest body of legislation intended to shield children from all forms of abuse (physical, sexual, emotional and psychological).

Federal laws provide standards and guidelines; however, most child abuse issues are governed by state laws and regulations. All states have enacted laws aimed at protecting children from abuse and neglect. Among the issues addressed in state law are mandatory reporting, responding to child abuse and neglect, and statutes of limitations for criminal and civil prosecution.2

Knowledge of the law is important in these cases as state laws all require all "mandated individuals," including doctors of optometry, to report cases of suspected child abuse. This report does not require proof of abuse, only reasonable suspicion or the knowledge to suspect abuse. The report will need to be called in or submitted in a written format in order for an investigation to be undertaken. Reporting agencies will vary from state to state, but may be a child protective service, a county department of family and child services, or law enforcement. One of the dilemmas is whether you notify or contact the parents about your suspicions before making the report. Such action could result in retribution against the child and the destruction of evidence. Penalties for failure to take this action with suspected child abuse by a mandated individual, may result in fines and imprisonment.

The AOA Code of Ethics does not directly address child abuse reporting, but the essence is seen in the statement, "to recognize the obligation to protect the health and welfare of society."3 Another important reference can be found in the AOA Standards of Professional Conduct document. Under Section C, Beneficence, there is a statement directed at protected populations: "Optometrists have the responsibility to identify signs of abuse and neglect in children, dependent adults and elders and to report suspected cases to the appropriate agencies, consistent with state law."

Many doctors focus attention and reporting on children and potential incidents of child abuse; however, the elderly are another population that a doctor frequently encounters and is ethically bound to protect.  Elder abuse and neglect are highly underreported in the United States. This may be partially attributed to the low incidence of reporting by health care providers, despite state-mandated reporting of suspected elder abuse.

Mandatory reporting laws (in all states except New York) require certain groups to tell designated authorities about reasonable suspicions of elder abuse. Information regarding mandated reporters and state-specific information on how to submit a report can be found at http://www.stetson.edu/law/academics/elder/ecpp/media/Mandatory%20Reporting%20Statutes%20fo
r%20Elder%20Abuse%202016.pdf
.  Just as is the case with suspected child abuse, a mandated reporter need only have a reasonable level of suspicion to submit a report to his or her state.

One commits elder abuse by subjecting a senior citizen to physical, emotional or sexual mistreatment; by neglecting or abandoning a senior; or by exploiting a senior for financial or material gain. Suspicions may arise in the doctor's office when a senior citizen who misses follow-up appointments for glaucoma treatment and is noncompliant with glaucoma medications. When asked about why the senior patient is noncompliant, the doctor may unearth a family situation where other family members have control of the patient's finances and do not allow him or her to purchase his or her medications. Further questioning may reveal that the patient's financial resources are being misused by his or her family members.

The provider has to balance confidentiality and trust with the need for patient safety. When there is a mutual, established, trusting relationship the physician can explain to the patient that it is his or her obligation to report even suspected cases of abuse. The goal is not to punish the victim or the abuser but to limit further abuse. Building a therapeutic alliance with the family may help. By not confronting the perpetrator and not blaming the victim, the doctor can assure the patient that safety is the desired outcome5.

Most experts agree that elder abuse usually happens in the victim's own home or the home of his/her caregiver, and the perpetrator frequently is a family member. Victims are often too confused about abusive acts, are kept isolated, are unwilling to report a family member, or may be unaware of the abuse if it is financial. A New York study in 2011 estimated that 260,000 (1 in 13) older adults in the state had been victims of at least one form of elder abuse in the preceding year. Another finding was that major financial exploitation was self-reported at a rate of 41 per 1,000 surveyed, which was higher than selfreported rates of emotional, physical and sexual abuse or neglect6. Careful observation of familial interaction and gentle questioning of the elderly patient presents a rare opportunity to bring more of these cases forward.

The legal and ethical considerations for reporting suspected child and elder abuse will overrule concerns with breaking confidentiality, which is another important legal and ethical obligation that doctors must honor.

Putting the federal and state requirements off to the side, the doctor still needs to be careful with followup procedures. Should the doctor notify the parents or caregivers at the time of the examination that a report will be submitted? This is not required and may create a very unpleasant disturbance in the office should that information be shared. The parent or caregivers may become argumentative and belligerent, thereby causing others in the office to become concerned or even afraid for their own safety. Such action will likely result in loss of these patients to the practice, but the highest ethical consideration is to place the patient's best interest ahead of the doctor's personal interests.

References:
1. CAPTA: A legislative history. Washington D.C. U.S. Department of Health and Human services,
Children's Bureau. Child Welfare Information Gateway, 2011
2. childwelfare.gov/pubs/factsheets/about.cfm
3. American Optometric Association, Code of Ethics. aoa.org
4. American Optometric Association, Standards of Professional Conduct. aoa.org
5. M. Ahmad and M Lachs. Elder Abuse, Cleveland Clinic J. of Medicine, V69(10), 2002.
6. Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, & New
York City Department for the Aging, 2011. Under the Radar: New York State Elder Abuse
Prevalence Study

About the Authors:
Dr. Morris Berman serves as Dean, MCPHS School of Optometry in Worcester, Massachusetts. He is a
member and former chair of the AOA Ethics and Values Committee and the ASCO Ethics Educator's SIG.

Dr. Amy Falk practiced in Rhode Island before joining MCPHS in 2014. She currently serves as Associate
Dean for Academic Programs and teaches posterior segment ocular disease courses including glaucoma.