Family Violence and the Emergency Physician: Legal and Ethical Considerations
By Arthur R. Derse, MD, JD, Associate Director for Medical and Legal Affairs, Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee, WI.Editor's Note: Violence has been declared a national public health epidemic. Child abuse, domestic violence, and elder abuse, often referred to collectively as family violence, have been on the rise.1 Emergency physicians are on the front line as a rising stream of patients present with traumatic injuries as the result of this foreboding trend. Emergency physicians, concerned about the legal ramifications of reporting suspected abuse and violating physician/patient confidentiality, may fail to recognize the implications of unreported family violence. Some emergency physicians may have a laissez-faire attitude toward an abused patient who is unwilling to cooperate in identifying and prosecuting the perpetrator. However, such physicians are at legal risk because the rising tide of precedent law and increased societal awareness of the devastating effects of family violence make the duty of diagnosing and reporting abuse part of the standard of care for all physicians.
DefinitionsFamily violence is intentional intimidation, physical and/or sexual abuse, and battering of children, adults, or elders by a family member, intimate partner, or caretaker. It includes child abuse and neglect (sometimes referred to as "child maltreatment"), domestic abuse (also known as spouse abuse or partner violence), and elder abuse (or elder mistreatment).2Abuse and neglect of children and elders are often defined by state statute.
Child abuse, domestic abuse, and elder abuse have different characteristics but a similar theme: infliction of injury by one family member to another. In any manifestation of family violence, sexual assault may accompany physical intimidation and violence.
Child Abuse and NeglectThe Child Abuse Prevention and Treatment Act of 1974,3which many states have adopted into statutory law, defines an abused child as any unemancipated person under 18 years of age whose parent, immediate family member, or any person who is responsible for the child's welfare who resides in the same home as the child or who is an intimate of the child's parent does one or more of the following:
1) Inflicts, causes to be inflicted, or allows to be inflicted upon the child physical injury, by other than accidental means, which causes death, disfigurement, impairment of physical or emotional health, or loss or impairment of any bodily function;
2) Creates a substantial risk of physical injury to the child by other than accidental means which would be likely to cause death, disfigurement, impairment of physical or emotional health, or loss or impairment of any bodily function;
3) Commits or allows to be committed any sex offense against the child;
4) Commits or allows to be committed an act or acts of torture upon the child; or
5) Inflicts excessive corporal punishment.
A neglected child is any person under 18 years of age whose parent or other person responsible for the child's welfare:
1) Withholds or denies nourishment or medically indicated treatment including food or care denied solely on the basis of the present or anticipated mental or physical impairment as determined by a physician acting alone or in consultation with other physicians.
2) Otherwise does not provide the proper or necessary support, legally required education, or medical or other remedial care recognized by law as necessary for a child's well-being, including adequate food, clothing, and shelter.4
Domestic ViolenceDomestic violence, spouse abuse, partner abuse, and battering all refer to the victimization of a person with whom the abuser has or has had an intimate or romantic relationship.5Because of the paucity of laws designed to address domestic violence, there is no generally accepted statutory definition.
Elder Abuse and NeglectAbuse of older adults includes physical violence as well as psychological or emotional abuse. Misappropriation of money and/or property, thefts of social security or pension checks, and the use of threats to enforce the signing or changing of a will or other legal documents are all considered elder abuse. Neglect of the elderly is a caregiver's failure to meet the needs of a dependent elderly person. It may be intentional or unintentional. There may be varying definitions of elder abuse among state agencies. Connecticut, for example, defines abuse as "the willful infliction of physical pain, injury, or mental anguish, or willful deprivation by a caretaker of services necessary for physical and/or mental well being."6,7
Scope of the ProblemIn the United States, the number of children reported as abused or neglected increased by 50% from 1985 to 1993, when nearly 3 million children were reported to child protective services agencies as suspected victims of child abuse or neglect.8Over half of these reports were substantiated after investigation by child protective agencies. As many as 5000 children per year die as a result of abuse.
Women account for over 95% of adult victims of domestic abuse. Estimates of the number of female victims of partner violence run as high as 4 million each year.11 Although statistics on elder abuse are less reliable, national estimates of reported incidence range up to 186,000 cases a year.12 State agencies, charged with identifying, investigating, and preventing elder abuse have all reported increased caseloads over the past decade.13
Duty To DiagnoseDoes an emergency physician have a duty to accurately diagnose the various types of abuse, and does failure to diagnose abuse constitute medical malpractice? The following cases address physicians' duties regarding diagnosing and reporting child abuse.
Case #1A mother brought her 11-month-old daughter to the hospital for medical treatment. After examining the girl, the attending physician diagnosed her as suffering from a comminuted spiral fracture of the right tibia and fibula. The child's mother had no explanation for the injury. The infant also had bruises over her entire back and superficial abrasions on other parts of her body. She also had a nondepressed linear fracture of the skull, which was in the process of healing. When approached, the child appeared fearful and apprehensive. The child was returned to the custody of her mother and her mother's boyfriend. Both had been physically abusing her, and the abuse continued. During one incident she sustained traumatic blows to her right eye and back, puncture wounds over her left lower leg and across her back, severe bites on her face, and second- and third-degree burns on her left hand. She was then taken to a different doctor and hospital, where she was diagnosed as having been battered. The incident was reported to the police and juvenile probation authorities, and she was taken into protective custody.
The plaintiff-infant claimed that the first physician failed to diagnose child abuse. The claim alleged that skull and long bone x-rays would have confirmed abusive injury. The plaintiff also alleged that the physician had a duty to report the diagnosed abuse to prevent her from further injury. The defendant physician argued that while there may be a standard of care for the correct diagnosis and treatment of the plaintiff's injuries, the standard of care does not include identifying an injury as being the result of child abuse. Therefore, duty to treat the child did not include a duty to identify child abuse. The defendant further argued that the plaintiff's later beating was a superseding cause of her injuries, thus relieving the physician of liability.
The California Supreme Court found for the plaintiff-infant, holding that the standard of care requires physicians to be able to diagnose and treat a battered child; additionally, if a diagnosis of child abuse is made, the failure to report it constitutes negligence. Finally, the Court held that injuries caused by the plaintiff's parents after the physician's failure to diagnose and report were reasonably foreseeable. The defense of a superseding cause for the child's ultimate injuries could not be used to shield the defendant physician.14
Case #2A 14-month-old girl's mother brought her to a family physician's office in June and July of 1992. On June 12, the child was diagnosed with a broken arm. On July 9, 1992, she was noted to have a "wobbly demeanor." On July 21, she was noted to have a swollen right temple and eye, and on July 22, it was noted that both eyes were swollen and bruised. The physician did not know that the mother's boyfriend was battering the child or that she would die as a result of the next beating on September 14, 1992.
In May 1993, the mother's boyfriend was arrested, convicted of first-degree murder, and sentenced to life in prison. Representatives of the child's estate sued the physician for malpractice. The claim alleged that the defendant had fallen below the standard of care. If she had not failed to recognize the pattern of injuries and had diagnosed child abuse, the child's death may have been prevented. An emergency physician testified as an expert witness against the defendant regarding the standard of care. The defendant argued that the failure to diagnose child abuse is not medical malpractice; that even if the diagnosis were made, there was no evidence that the diagnosis would have prevented the child's death; and that an emergency physician could not testify as to the standard of care for a family practitioner.
The trial court agreed with the defendant. However, the Arkansas Supreme Court reversed the decision, holding that medical practitioners could be found liable for failing to diagnose abuse. The Court also stated that whether the diagnosis would have prevented the child's death is a question for the jury, and "the knowledge necessary to evaluate a potential child abuse situation is one that is basic to the science of medicine and is the same regardless of whether the physician had a family medicine practice or an emergency room practice."15
The Court ordered a new trial, which ended on September 26, 1996, with the jury deciding that the physician should have diagnosed child abuse and notified authorities. The estate of the murdered child was awarded $200,000.16
In more difficult to diagnose cases of child abuse, some state statutes require that professionals evaluate the facts known to them, in light of their training and experience, to determine whether it is reasonable to suspect child abuse, thus establishing a duty to report. At least one court, however, has held that such a statute did not require health practitioners to elicit information not ordinarily obtained in the course of providing care or treatment.17 Although the defense that there is no standard of care to diagnose child abuse failed in California and Arkansas, it has been successful in other jurisdictions.18
The Diagnosis of Abuse and Neglect
The Diagnosis of Child AbuseThe single most important element in diagnosing child abuse is when the history of the injury is inconsistent with the apparent injury.
The Diagnosis of Domestic AbuseEmergency physicians are also apparently missing important indicators of partner violence.(See Table 2.) One study showed that 30% of all injured women who present to an ED acquired the injuries as a result of battering by their partner.20Another study showed that 11.7% of women who present to an ED for any reason are victims of domestic violence.21Approximately one in five battered women presenting to physicians will have sought medical attention for domestic abuse injuries 11 times before.22
One abused woman presented to an ED seven times in 15 months with injuries that included broken bones and stab wounds. None of the physicians or nurses ever addressed the nature of the woman's injuries or asked about the possibility of domestic abuse. They simply treated each injury and sent her back home.23
It should be easier to diagnose domestic abuse than child abuse, because an adult patient is capable of telling about the abuse in the history. Yet studies depict an appalling failure to diagnose domestic abuse, due in part to the patient's unwillingness to disclose the abuse and in part because emergency physicians do not always ask whether the patient has been abused, even when they may suspect it. Possible indicators of domestic abuse in the patient's history include delay in seeking care, a mechanism that does not fit the injury, the patient claiming to be "accident-prone," substance abuse by either the patient or partner, history of the patient's children being abused, family stress, patient evasiveness, patient depression, adamant denial of even the possibility of abuse, minimizing injuries, demonstrating inappropriate responses, or deferring to the partner's description of the injury mechanism.
Typical findings in domestic abuse include facial injuries, breast or abdominal injuries (particularly during pregnancy), internal injuries, mid-arm injuries due to defensive posturing, injuries at various stages of healing, injuries to multiple sites, bites, and scald and cigarette burns. The risk of domestic abuse frequently escalates during pregnancy.24
The Diagnosis of Elder Abuse and NeglectCharacteristics of elder abuse are similar to those used to identify domestic abuse(see Table 3): delay in seeking care for an injury; injury inconsistent with history; lacerations, bruises, and ecchymoses in various stages of healing; multiple fractures; and scald and cigarette burns. Additionally, conflicting injury reports by the patient and caregiver and patient inability to describe the injury may be indicators of elder abuse. High-risk situations conducive to elder abuse include caregivers who have a history of alcohol or drug abuse, mental illness, stress, or problems controlling their tempers. Caregivers who are dependent upon the elder for housing or money may be abusive. When the elder's problems are progressive or unstable and exceed the caregiver's ability to cope, there may also be risk for abuse.
Elder neglect may be most observable to prehospital care providers. Indicators include airless quarters, lack of food in the house, the patient being either locked in a room or placed in restraints while no one is home, dehydration, malnutrition, and the presence of bed sores.25
The Duty To Report
Reporting Statutes, Criminal Penalties, and Civil LiabilityChild Abuse. Every state has enacted statutes requiring that child abuse be reported to the authorities. Many of the child abuse statutes were enacted soon after Children's Bureau of the Department of Health, Education, and Welfare published a model statute in 1963. The model statute required physicians to report suspected child abuse, and made it a misdemeanor for physicians who knowingly and willfully failed to report it.
Statutes vary regarding the types of abuse or injuries subject to the reporting requirement. Some states require a report only when the injuries are "serious" or "severe." In other states, injuries must be reported if the physician thinks they have been suffered by other than accidental means or are indicative of abuse or neglect. Most statutes require reporting when there is "reasonable cause to believe" or "reasonable suspicion" that abuse or neglect has occurred.26
All child abuse statutes provide immunity from civil liability for physicians who report suspected child abuse. Some require that the reporting be done "in good faith." This immunity extends to suits for slander, libel, breach of confidentiality, and invasion of privacy.27 For example: "[Any] . . . medical practitioner . . . who has knowledge of or observes a child in his or her professional capacity or with the scope of his or her employment whom he or she knows or reasonably suspects has been victim of child abuse shall report the known or suspected instance of child abuse to a child protective agency immediately or as soon as practically possible by telephone and shall prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. No . . . medical practitioner . . . who reports a known or suspected instance of child abuse shall be civilly or criminally liable for any report required or authorized by this article."28
The above statute gives physicians immunity for reporting child abuse under all circumstances. An emergency physician reporting according to this statute, is immune, whether the report is true or false, made in good faith or not.
Although California and a few other states grant absolute, unqualified immunity, most provide only limited immunity for "good faith" reporting.29 "Good faith [e]ncompasses, among other things, an honest belief, the absence of malice and the absence of design to defraud or seek an unconscionable advantage."30 A presumption of good faith is established by some statutes.31
One state statute requiring that the report be made in "good faith," states: "Any person . . . participating in good faith in the making of a report . . . shall be immune from any liability, civil or criminal, that results by reason of the [reporting] (emphasis added).32
Immunity may also be expressly limited to reporters having "reasonable cause" to suspect abuse or neglect. Although many states also provide misdemeanor criminal penalties for failure to report,33 there have been no criminal prosecutions for failure to report.34
Elder Abuse. All states have passed legislation intended to curb elder abuse, and 42 states have adopted laws requiring healthcare professionals to report abuse or neglect to a state agency.35 Additionally, Colorado, New York, and Wisconsin have voluntary reporting laws which state that abuse "may be reported" instead of mandating that it "shall be reported." 36 Despite these laws, surveys show that most emergency personnel are unaware of the legislation and the need to report,37 thus making intervention and prevention of further abuse more difficult.
States have differing standards for immunity in erroneously reporting child and elder abuse. For instance, New Jersey grants absolute immunity for those who err in reporting child abuse, but grant immunity for erroneous reports of elder abuse only if it is done in good faith.38
Domestic Abuse. In contrast to child and elder abuse, most states do not have reporting requirements for domestic abuse or the concomitant immunity provisions to protect physician reporters.39 One state explicitly grants immunity and allows reporting at the discretion of the individual, but does not require the reporting of spousal abuse.40
Failure to ReportCourts do not agree about whether physicians who suspect or diagnose abuse and fail to report it should be held civilly liable for subsequent injuries a patient may suffer.
However, both California and Arkansas Supreme Courts found that a failure to report child abuse could be used to show negligence that then resulted in foreseeable harm to the injured plaintiff. Thus, if the harm was foreseeable and the failure to report was the proximate cause of the harm, the defendant physician may be liable.
The following case addresses failure to report child abuse.
Case #3A woman discovered three red marks on the chest of her 1-month-old daughter and sought medical treatment for the child at an ED. The child was examined by a physician. The mother feared that the child's father had struck the child, but when she was questioned by the physician, she stated that the child had not been subjected to trauma. She asked the physician whether the red marks might not possibly be bite marks that had been made by another of her young children. The physician ordered no x-rays and prescribed a pain reliever for bruises. One month later, the child was murdered by her abusive father. After the child's death, her mother and the administratrix of the child's estate alleged failure to report suspected child abuse.41The Georgia Court of Appeals held that although the Georgia statutes required reporting, no private cause of action is created by the statute. Thus, the state may impose sanctions for failure to report abuse, but the individual who is injured may not recover damages.
Other appellate courts have agreed that mandatory reporting statutes will not give rise to a private cause of action against a physician for failing to report child abuse.42,43 Emergency physicians should either know their state's approach or should err on the side of diagnosing and reporting.
Errors Made While Reporting
Abuse and Statutory ImmunityThe following cases discuss how mistaken reports of child abuse have been addressed by the courts.
Case #4A physician diagnosed a couple's child as having malnutrition, and reported the child's parents to the authorities for child abuse and neglect. After the child was placed in temporary foster care, it was discovered that the child was suffering from malabsorption syndrome, cirrhosis, and fibrosis of the liver. The child was then returned to the parents. The parents sued the physician and the medical center for malpractice, alleging that the defendant physician negligently diagnosed their child's malnutrition as child abuse and neglect.
The plaintiff's argument stated that the statutory immunity for good faith reporting of suspected child abuse or neglect should not protect a physician from liability for a report based on a negligent diagnosis. The Iowa Supreme Court rejected the argument and concluded that the legislature granted immunity with the understanding that a physician might be negligent, and that to permit liability for mere negligence would discourage those suspecting abuse from reporting.44,45
This case is an example of blanket immunity for reporting. There is no need to show "good faith." Plaintiffs in states whose statutes do not require good faith have an even higher hurdle to overcome when alleging negligence in diagnosis or reporting.
Case #5According to hospital records, a baby born on November 30,1992, became ill in December 1992 and was taken to a hospital ED. The baby had developed a fever and demonstrated symptoms consistent with seizures. The baby was initially treated at this hospital but was then transported to another hospital for further care. The defendant treated the baby upon her arrival at the second hospital. He ordered a CT scan of the baby's head to determine the cause of her seizures. The results showed that the baby had a diffuse subarachnoid hemorrhage. The report noted that "on the basis of this examination alone, the possibility of Battered Child Syndrome cannot be excluded." Upon this finding, the physician noted that he was "obligated to pursue follow-up since it could be 'Shaken Baby Syndrome'." the physician reported the injury to social services. Upon investigation, social services removed the baby from her parents' home, and the father was charged with child abuse. The charges later proved unfounded and the father sued the physician for negligent diagnosis and reporting.
Plaintiffs argued that the physician clearly did not have "reasonable cause" to suspect child abuse since the child's injuries were "the obvious result of birth trauma and that even a minimally trained pediatrician should have determined this." But the Federal District Court held that even if the physician did not have reasonable cause, the physician was protected by statutory immunity: "[B]ecause doctors are required to report for fear of criminal charges in failing to do so, it is reasonable to conclude that the legislature felt a responsibility to ensure that if doctors reported a suspected case of child abuse which ultimately turned out to be unfounded, they would not be held liable for their misdiagnosis unless it was done with bad intent."46
This case applies the "good faith" standard. Since the plaintiffs alleged negligence and not bad faith in reporting, the Court's application of the law resulted in essentially the same outcome as Case #3. Both cases reflect the legislative intent of setting the balance toward protecting children by allowing the possibility of error in diagnosing and reporting suspected abuse to far outweigh any putative harms that might come to the person erroneously accused of child abuse.
Courts have frequently questioned whether circumstances in particular cases were sufficient to establish a "reasonable cause" to suspect child abuse. They have also questioned whether a suspected child abuse report was submitted in "good faith." Statutory immunity may depend on establishing "reasonable cause," "good faith," or both. "Reasonable cause" most often arises when litigants dispute whether a particular party had a duty to report suspected abuse. Frequently, the same set of facts establish both "reasonable cause" and "good faith." Courts have held that the facts were sufficient to establish "reasonable cause" to suspect child abuse and/or "good faith" reporting, in cases where individuals who observed a child's injuries received either a dissatisfactory explanation or no explanation about the cause of injury from the child's parent(s). To date, no person identified by statute as a mandatory reporter has been denied statutory immunity for reporting suspected child abuse, since no lack of "good faith" or "reasonable cause" has been found in cases applying those requirements for immunity.47
Patient Confidentiality and Abuse Reporting
Child AbusePotential conflicts may arise regarding the physician's duty to report suspected child abuse and the physician-patient privilege. Most reporting statutes abrogate the physician-patient privilege to the extent that it conflicts with the reporting requirement.48Since all states have mandatory child abuse reporting requirements, abusive parents' desire for confidentiality will not affect the duty of the emergency physician to report.
Elder AbuseMost states have mandatory reporting requirements that supersede the duty to maintain confidentiality. A few states have permissive statutes stating that the emergency physician may report the abuse but is not required to do so. In those states, emergency physicians must weigh the elder's potential benefit from the report (for example, prevention of future harm) against any immediate harm or continued abuse that may occur if it is not reported.
Domestic AbuseFrequently, the victim of domestic abuse will admit that she has been abused but will plead with the emergency physician not to report it. The police and the district attorney have a much more daunting task investigating and prosecuting when the victim is a reluctant witness against her abuser. Nevertheless, the emergency physician should document the historical and physical evidence of abuse and urge that the patient accede to reporting.
If the patient still asks that the abuse not be reported, the emergency physician should recommend counseling and may consider reporting it nonetheless. The risk to the patient from future abuse is great, and the patient is often dependent upon her abuser. She may need support to admit that she is being abused. Although there is risk of further abuse once abuse is reported, there is also risk in allowing abuse to continue unreported and unabated. If victims and physicians maintain a conspiracy of silence, the epidemic of abuse may continue to escalate. Victims of domestic abuse may need both counseling and shelter. Hospital social services departments and many police departments have trained individuals to counsel victims willing to prosecute their abusers. A recent search found no cases that have been reported where a domestic abuse victim has successfully sued a physician for breach of confidentiality in reporting acknowledged abuse to the appropriate authorities.
On the other hand, some other authors have cautioned that "[s]pouses, partners, or other third parties, including the police [emphasis added], should not be notified of an abuse diagnosis without the expressed consent of the patient," citing the need for patient autonomy and empowerment. These authors argue that, in contrast to policy in cases of suspected child abuse, "It is not evident . . . that mandatory reporting of domestic violence [by physicians] would contribute to the safety of battered women or would facilitate their access to appropriate resources."49,50
Therefore, in the case of the patient who is unwilling to report, the emergency physician must carefully weigh the harms to patient confidentiality and autonomy against the likelihood of benefit from reporting.
It is particularly vexing when an emergency physician strongly suspects domestic abuse and the victim denies it. When this occurs, a social worker or nurse specifically trained to address domestic abuse may be able to work with the victim in a non-threatening way. Since emergency physicians do not have a mandatory duty to report abuse in most states, and only a few states have immunity for good faith mistakes, the harm of both disbelieving the patient and reporting the abuse in error would seem to outweigh the likelihood of benefits from reporting if the suspicion is correct.
Emergency physicians may be surprised to find little guidance in this area from their hospital policy. Since 1991, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has had a requirement that hospitals and their EDs have written policies and procedures as well as and staff training that includes identifying, treating, gathering evidence, and reporting and referring victims of domestic violence. A study done by the Arizona Department of Health showed that only 30% of the EDs in that state had any such policies, and only one-sixth of those were in total compliance with the requirement.51 Emergency physicians should make sure their departments have policies pertaining to domestic violence and be familiar with them.
SummaryEmergency physicians will continue to encounter victims of family violence. They must be prepared to accurately diagnose and report both child and elder abuse. As in cases of child abuse, state laws mandate breaching confidentiality to report domestic and elder abuse. However, state statutes often do not grant emergency physicians immunity when they report suspected cases of domestic abuse. Emergency physicians should become familiar with their state's laws regarding diagnosing and reporting all types of family violence.
The author wishes to thank Mary Olson of the Center for the Study of Bioethics for her editorial assistance.
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7. State of Connecticut. General Statutes. Chapter 319h. Sect. 17A-430.
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12. Tatara T. Toward the development of estimates of the national incidence of reports of elder abuse based on currently available state data: An exploratory study. In: Filinson R, Ingman SR, eds. Elder Abuse: Practice and Policy. New York, NY: Human Sciences Press; 1988:153-164.
13. Tatara T. Understanding the nature and scope of domestic elder abuse with the use of state aggregate data: Summaries of key findings of a national survey of state APS and aging agencies. J Elder Abuse Neglect 1993;5:35-57.
14. Landeros v. Flood, 17 Cal. 3d 399; 551 P.2d 389; 131 Cal. Rptr. 69; 97 A.L.R.3d 324 (1976).
15. Estate of Laura Allison Fullbright v. Joseph John Rank, Mary Ellen Robbins, and Rheeta Stecker, M.D., 323 Ark. 390; 915 S.W.2d 262 (1996).
16. Doctor cited for malpractice after ignoring abuse. American Medical News October 28,1996;8:col.2.
17. David M. v. Erie County Department of Human Services 1994 Ohio App. LEXIS 2785 (6th Dist. Ct. App. 1994).
18. People v Stockton Pregnancy Control Medical Clinic, Inc. (1988, 3rd Dist) Cal App 3d 225, 249 Cal Rptr 762.
19. Sheridan C, Mellick LB, Sherwin T. Recognizing child abuse and neglect: The role of the emergency physician. Emerg Med Rep 1993;14:67-74.
20. McLeer SV, Anwar R. A study of battered women presenting in an emergency department. Am J Public Health 1989;79:65-66.
21. Abbot J, Johnson R, Koziol-McLain J, et al. Domestic violence against women: Incidence and prevalence in an emergency department population. JAMA 1995;273:1763-1767.
22. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting: An introduction for health personnel. Washington, DC: Office of Domestic Violence; 1981. Monograph 7.
23. Congdon TW. A medical student's perspective on education about domestic violence. Acad Med 1997;72:S7-S9.
24. deLahunta EA. Partner abuse: Recognition, evaluation, and management of battered women in the emergency setting. Emerg Med Rep 1996;17:13-22.
25. Stewart C. Confronting the grim realities of elder abuse and neglect. Emerg Med Rep 1991;12:179-186.
26. 73 A.L.R.4th 782, §2
27. 73 A.L.R.4th 782, §2
28. Malpractice-Physician's Liability for Failure to Diagnose and Report Child Abuse. 23 Wayne L. Rev. 1187,1191 (1977). As cited in: McMenamin JP, Bigley GL. Children as patients. In: Sanbar SS, ed. Legal Medicine. St. Louis, MO: Mosby; 1995:475-487.
29. Cal. Penal Code § 11166 (West 1992). As cited in: Bisbing SB, McMenamin JP, Granville RL. Competency, capacity, immunity.. In: Sanbar SS, ed. Legal Medicine. St. Louis, MO: Mosby; 1995:27-45.
30. 73 A.L.R.4th 782, §2
31. 73 A.L.R.4th 782, §2
32. Wisconsin Statutes § 48.981(4) (1995-1996).
33. E.g. Cechman v. Travis, 414 S.E.2d 1282,284 (Ga. Ct.A App. 1991) (in dicta), cert denied, (1992). As cited in: McMenamin JP, Bigley GL. Children as patients. In: Sanbar SS, ed. Legal Medicine. St. Louis: Mosby; 1995:475-487.
34. McMenamin JP, Bigley GL. Children as patients. In Sanbar SS, ed. Legal Medicine. St. Louis, MO: Mosby; 1995:475-487; updating Kohlman. Malpractice Liability for Failure to Report Child Abuse, 49 Cal. St. B. J. 118, 121 (1974).
35. Culhane C. Federal, state effort urged to prevent elder abuse. Am Med News July 21, 1989;18-19. As cited by: Clark-Daniels CL, Daniels RS, Baumhover LA. Abuse and neglect of the elderly: Are emergency department personnel aware of mandatory reporting laws? Ann Emerg Med 1990;19:970-977.
36. Brewer RA, Jones JS. Reporting elder abuse: Limitations of statutes. Ann Emerg Med 1989;18:1217-1221.
37. Clark-Daniels CL, Daniels RS, Baumhover LA. Abuse and neglect of the elderly: Are emergency department personnel aware of mandatory reporting laws? Ann Emerg Med 1990;19:970-977.
38. Rubinstein v Baron (1987) 219 NJ Super 129, 529 A2d 1061.
39. Bisbing SB, McMenamin JP, Granville, RL. Competence, capacity and immunity. In: Sanbar SS, ed. Legal Medicine. St. Louis, MO: Mosby; 1995:41-42.
40. Bisbing SB, McMenamin JP, Granville, RL. Competence, capacity and immunity. In: Sanbar SS, ed. Legal Medicine. St. Louis, MO: Mosby; 1995:41-42.
41. Cechman v. Travis, 202 Ga. App. 255, 414 S.E.2d 282 (1991)
42. Valtakis v. Putnam, 504 N.W.2d 124 (Minn. Ct. App. 1993).
43. Marcelletti v. Bathani, 500 N.W.2d 124 (Mich. Ct. App. 1993).
44. Maples v. Siddiqui, 450 N.W.2d 529 (Iowa 1990).
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46. Hazlett v. Evans, 943 F. Supp. 785 (E.D. Ky. 1996).
47. 73 A.L.R.4th 782, §2
48. 73 A.L.R.4th 782, §2
49. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence: Ethical considerations. JAMA 1992;267:3190-3193.
50. Flitcraft AH. Violence, values, and gender. JAMA 1992;267:3194-3195.
51. Bedard L. Domestic violence can no longer be tolerated. ACEP News October 1996, page 2.
Physician CME Questions
All of the following regarding family violence are true except:
a. All forms of family violence (child abuse, domestic abuse, and elder abuse) have been rising.
b. Evidence shows that emergency physicians easily recognize when traumatic injuries are due to the effects of domestic abuse when injured women present to the ED.
c. As many as 30% of all women who report to an ED for injuries acquired those injuries as a result of battering by partners.
d. One out of nine women who present to an ED for any reason are the victims of domestic violence
e. Approximately one in five battered women presenting to physicians had sought medical attention for injuries from abuse 11 times previously.
The single most important element in the diagnosis of child abuse is:
a. the history being inconsistent with the apparent injury.
b. the injury itself being pathognomonic for child abuse.
c. radiologic evidence of fracture in the long bones.
d. a stressed parent who appears uninterested in the child's injury.
Which of the following is/are correct?
a. Courts have been reported to have held a physician liable for failing to diagnose child abuse.
b. Courts have been reported to have held a physician liable for failing to report child abuse to the proper authorities.
c. No court has been reported to have held a physician liable for reporting child abuse in bad faith.
d. All 50 states have enacted some type of statute requiring cases of child abuse to be reported to various authorities.
e. All of the above.
In which of the following does the duty to report abuse most clearly supersede the confidentiality of the physician/patient relationship?
a. Child abuse, because the states have enacted laws that clearly supersede the common law of confidentiality, and the physician's duty is to the child, who is that patient, and not the parents.
b. Domestic abuse, because of the possibility that the victim will be harmed again.
c. Elder abuse, because the victims might be intimidated into requesting confidentiality.
d. None of the above. Confidentiality should be maintained under all circumstances.