'Reasonable suspicion' in suspected child abuse cases
Ethicist seeks to quantify a non-specific concept
Health care providers are among groups ethically and legally obligated to report suspected child abuse. But does the wording of child abuse reporting laws create an ethical quandary for doctors who must decide for themselves the definitions of terms such as "reasonable suspicion" and "belief?"
"As clinicians, we live with the uncertainty of the diagnoses we make," explains Benjamin H. Levi, MD, PhD, FAAP, a philosopher and associate professor of humanities and pediatrics at Penn State University. "What's challenging is that unlike in clinical medicine, where there are accepted standards, guidelines, and evidence-based medicine, what my research — and that of others — has shown is that there is no standard for what the term 'reasonable suspicion' means."
That leaves it up to the individual who is mandated to report suspected abuse to decide for himself or herself what the standard is.
"I think it proves a heavy burden on people trying to figure out what they are supposed to do," Levi continues. "It asks us to use a screening test where we don't know the sensitivity or specificity of that test, and as a result, it does a poor job generating true positives when we report."
Levi has led several studies into clinicians' attitudes toward mandatory reporting and their interpretations of "reasonable suspicion" and "reasonable belief," and his findings may best be summed up by the conclusion drawn in one of the reports:
"Our data show significant variability in how pediatricians interpret reasonable suspicion, with a range of responses so broad as to question the assumption that the threshold for mandated reporting is understood, interpreted, or applied in a coherent and consistent manner" or "that any general consensus exists."1
Belief vs. known fact
Lawmakers nationwide generally have worded statutes on mandatory child abuse reporting vaguely, to encourage reporting of suspicions. Use of terms such as "suspicion" and "belief" rather than "knowledge" or "known fact" is a protective measure that allows reporting of suspected child abuse without the presence of verified proof.
Some states require "belief," as in "I believe this child is being abused," while others use the term "suspicion," allowing the somewhat less-certain threshold of "I suspect this child is being abused."
Levi says that there is a problem with relying on "belief," in that "it involves holding an idea to be true, whereas in the context of mandated reporting, one is seldom sure that abuse occurred, but instead concerned that it might have."
All statutory thresholds on child abuse reporting fall under the legal umbrella of reasonable suspicion, Levi explains, and mandated reporters are told that they must report any time they reasonably suspect a child is being abused.
But what does "reasonable suspicion" mean? Levi maintains that it means something different to everyone, and there is too little definition given to allow a consistent application of the term.
For some, it can mean a fleeting notion that abuse might have occurred; to others, it may mean there is a significant indication that abuse has taken place.
For example, Levi's survey of more than 2,000 pediatricians found that 15% of respondents said that abuse would need to be better than 75% likely to qualify as reasonable suspicion; but a quarter of respondents set the threshold at a 60-70% likelihood, and another quarter set it at 40-50%. More than one-third (35%) set the threshold as low as 10-35% probability.1
"Classically, the idea of a belief is the holding of an idea to be true," he explains. "This, I think, is confusing for those states where the threshold for statutory language reporting is framed in terms of belief, because it sends a mixed message. On one hand, you supposed to believe what's true, and on the other hand, you're supposed to have a low bar for suspicion to report [potential abuse]."
The ethical dilemma that results is whether to suspend the notion of whether abuse is believed and report a suspicion of abuse — thereby perhaps making a report that proves to be unfounded, or to hold out for signs that lead one to believe abuse has occurred, and thereby perhaps not reporting suspicions that later prove to be true.
"Given the burden to families that investigations pose, it gives rise to injustice in terms of what our reporting does to families," he says, in addition to overburdening already taxed investigative and social services resources. On the other hand, under-reporting leads to the feared result of missing true abuse cases.
Adding to the problem, Levi says, is that there are so many groups of mandated reporters in the United States — as many as 70 million people — and all, from bus drivers to day care providers to doctors to teachers, are expected to be able to reach some sort of consensus on what the terms "reasonable suspicion" and "reasonable belief mean."
Despite the size of the group, Levi believes consensus is possible.
"I think you can create a consensus, and I think estimated probability is the way to go," he suggests. "People prefer to receive information about probability numerically."
For example, if police officers are told to ticket drivers who are going "too fast," without any speed limit to use as a basis, tickets would be issued for a broad range of speeds.
"If the law or policy set a numerical threshold, maybe 50% probability or 35% probability — and that's something that there would have to be agreement reached on — then reporters would be able to look at that number and decide whether their suspicion reaches that level of probability," he adds.
Critics of Levi's proposal say many people don't understand probability, but he disagrees.
"If people are told, 'There's a 75% chance of rain,' rather than, 'There's a likelihood of rain,' most would take umbrellas with them, because they understand the probability," he suggests.
Even if statutes were revised to include probabilities, Levi is quick to point out that reporters will not be able to always agree. But given a ballpark number to work with, "you'll get better agreement — not perfect, but better," he says.
Both practically and conceptually, significant problems arise from the current lack of direction on reporting, Levi says, including inconsistent reporting of possible abuse, unequal protection of children, inequitable treatment of parents, and inefficient use of child protection service resources.
"We owe it to people to be able to define that. I would argue it could violate due process, and it's bad for kids," he says.
- Levi BH, Brown G. Reasonable suspicion: A study of Pennsylvania pediatricians regarding child abuse. Pediatrics 2005;116;5-12.
- Benjamin H. Levi, MD, PhD, FAAP, associate professor, departments of humanities and pediatrics, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, PA. Phone: (717) 531-8778. E-mail: firstname.lastname@example.org.