Reporting laws put patients in danger
By Linda Hutson, RN
University Hospital Medical Center
Emergency Department
Cincinnati, OH
When a patient confides in you that they have a problem with violence, what is your responsibility as a health care provider? How far must you legally go? When should you stop? It is certainly our responsibility to know our state and local laws related to domestic violence and how they affect licensure. It is also our responsibility to educate ourselves on recognition of the high-risk indicators, high-risk history, and high-risk injuries that are typical of domestic violence.
In the midst of all this information, you must also remember that your patient is a competent, adult female (95% of domestic violence victims are female1) who makes decisions for herself every day without your help. Should part of your care involve calling the police even if the patient does not want police involvement? Absolutely not.
Unlike child abuse and elder abuse, we are working with a victim who can take care of herself. If she wants our help or police intervention, she will decide when the right time is to ask. Her decision of when to confide in someone or report to the police may be directly proportional to how safe she can keep herself. FBI statistics indicate that a woman's risk for injury or death increases 75% when she decides to report domestic violence or leave a violent relationship. Health care workers cannot make this decision for patients.
Providers should offer help, information
The solution can't be provided by the ED staff. But, as a health care provider, I can fulfill my obligation by reporting, identifying, and documenting domestic violence. I can uphold the law by offering to photograph injuries and offering community referral services. If I ask my patient about domestic violence and she says that "yes," violence is the cause of her injury and she fears for her life, she may then retract her statement when the police arrive so she can provide for her safety and the safety of her children. It is likely that mandatory reporting will decrease the willingness of some battered women to seek medical care because it will only serve to further jeopardize their health and safety.
The time and resources used to implement mandatory reporting laws would be better used providing domestic violence educational training, and departmental policies that make screening of all females mandatory. The health care system is responsible for providing an adequate response to this epidemic. Providing recognition, documentation, and information may be the very salve necessary for this wound. Documentation of injuries can be extremely useful for criminal and civil prosecution, even if the patient does not initially want to pursue that avenue. She may change her mind in the future and documentation of past incidents could be extremely valuable.
Furthermore, use of the medical record by law enforcement and prosecution is preferable to mandatory reporting, because it provides the patient with the confidentiality and autonomy that reporting cannot guarantee. Victims of domestic violence should be empowered to make their own decisions, and health care providers should be educated to respect the patient's decisions based on her knowledge and the experience of her situation.
Mandatory reporting robs victim of control
Mandatory reporting would be re-victimizing the patient, by taking control out of her hands, exactly like the batterer in her life. There is good reason to believe that mandatory reporting would pose a serious threat to the health and safety of battered women as patients. Health care providers would better serve the patient by encouraging police reports and describing the benefits of reporting, pursuing legal options, and accessing community resources. The benefits of mandatory reporting have not been adequately proven to justify destroying the provider-patient confidentiality bond.
In June 1997, the American Medical Association (AMA) House of Delegates adopted the position that the organization should oppose mandatory medical reporting of competent, adult victims of domestic violence. Furthermore, the AMA encouraged states with such laws to repeal them, especially any aspects of the laws that might compromise victim safety. Currently, AMA policy 515.983(6) (1991) states that "for competent adult victims, physicians must not disclose an abuse diagnosis to caregivers, spouses, or any other third party without the consent of the patient." Also, the Council on Ethical and Judicial Affairs opinion 2.02 tells physicians to routinely screen patients for physical, sexual, and psychological abuse, but not to disclose the diagnosis for an adult patient to anyone without the patient's consent.
Clearly there is a conflict present with this issue and health care providers. Mandatory reporting provides a valuable service when used appropriately, but it is a clear and present danger for competent, adult victims of domestic violence.
My first responsibility is the recognition, discussion, and treatment of domestic violence in all female patients so that I can do my part to prevent future injury to the woman and her children. When my patient requests police intervention, I will accommodate her request. But, until that time, I will continue to report all shootings, stabbings, and suspicious burns as required by law, but otherwise allow the reporting to remain in the control of the victim-the one person best qualified to assess her own safety.
Reference
1. Dobash R, Dobash E. Violence against Wives: The Case against Patriarchy. London: Open Books; 1980.
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