The John M. Rezendes Ethics Essay Competition
MANDATORY REPORT OF INTIMATE PARTNER VIOLENCE INJURIES BY HEALTH CARE PROFESSIONALS: AN ETHICAL DILEMMA FOR NURSES
Ashley E. Schumacher (Women’s Studies & Nursing) 2007
Intimate partner violence is a pattern of assaultive and coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent, and are aimed at establishing control by one partner over the other. (Family Violence Prevention Fund, 2002, National consensus guidelines, p. 2) Introduction: Intimate Partner Violence as a Public Health Concern Intimate partner violence (IPV) is a wide-ranging and devastating health problem in the United States. According to Terebelo (2006), 25% of women and 7.5% of men have experienced physical and/or sexual violence from an intimate partner at some point in their lives. Further, 41.5% of women and 19.9% of men who had recently experienced violence suffered injuries as a result. However, the definitions of violence and abuse are subjective; Lewis-O’Connor (2004) demonstrates this by citing two studies: in 2003 a study noted 691,710 incidents of violence by “current or former spouses” (¶ 2) nationwide, while a separate study in 1999 using broader definitions estimated that there are 3 million annuals cases of IPV. Terebelo (2006) outlines IPV as a public health concern both by the long term effects of abuse on victims, as well as the financial costs incurred by violence between partners. She uses the available research to say that IPV is responsible for “2 million injuries and 1,300 deaths yearly in this country and costs $5.8 billion a year, about 75% of which goes for direct medical costs and the remainder for lost productivity” (p. 30). In addition, she notes some of the chronic health effects victims of IPV may suffer including, but not limited to: fainting, migraine headaches, irritable bowel syndrome, chronic pelvic pain, sexual dysfunction, urinary tract infections, vaginal bleeding, sexually transmitted infections, chronic neck and back pain, depression, suicide attempts and substance abuse. Studying the available statistics, it becomes apparent that IPV is a public health concern of significant proportions in this nation.
Because the majority of IPV occurs against women, the author will predominantly refer to victims of IPV using feminine nouns and pronouns (i.e., women, she, her, etc.). However, it should be noted that IPV occurs in all social groups, including men and homosexual populations. In addition, because the vast majority of IPV is perpetrated by men, this essay will refer to abusers using masculine nouns and pronouns while staying aware that women are capable of and perpetrate violence as well. Mandatory Reporting of Intimate Partner Violence Injuries To date, six states have comprehensive mandatory reporting of IPV by positive disclosure or suspicion: California, Colorado, Kentucky, New Hampshire, Rhode Island, and New Mexico. The laws differ from state to state, however. For instance, in New Hampshire, a patient who is over age 18 and is not the victim of a gunshot wound and does not consent to reporting should not be reported. In Rhode Island, the reporting done is anonymous and serves the purposes of data collection only (Family Violence Prevention Fund, 2002, Identifying; Lewis-O’Connor, 2004; Rodriguez, Sheldon, & Rao, 2002; Terebelo, 2006). The ethical issue at stake in this essay is the mandatory reporting of IPV injuries to police by nurses. Proponents of mandatory reporting name four benefits of mandatory reporting laws, saying that these laws “facilitate the prosecution of perpetrators, help identify victims, promote intervention, and improve data collection” (Lewis-O’Connor, 2004, ¶ 15). This essay will demonstrate ways in which each of these goals may not be accomplished using mandatory reporting laws. It will do so by demonstrating how these laws violate the ethical nursing principles of nonmaleficence, patient autonomy and confidentiality, and the international code of ethics for nurses. Finally, this essay will call for universal screening for IPV for all female patients and nurse advocacy for patients.
Ethical Principles for Nurses Health care professionals practice under and are bound to set ethical codes. Nursing, as a profession has its own codes of ethics which are based on the principles of autonomy, confidentiality, and nonmaleficence among others (Harkreader & Hogan, 2004). Below is an overview of ethical codes and principles as they apply to mandatory reporting of IPV injuries. Codes of Ethics for Nurses Nurses operate under and are responsible to the above mentioned ethical codes for practice. One such code is the International Council of Nurses Code of Ethics for Nurses (2006, hereby referred to as the ICN Code) The first lines in the preamble of the ICN Code read as such: Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, the right to life and choice [italics added], to dignity and to be treated with respect. (p. 1) Mandatory reporting violates a patient’s right to choice, the right to self-determination. By making report to police mandatory, the provider is effectively taking away the patient’s right to choose how to be safe from harm. Another code is the American Nurses’ Association Code of Ethics for Nurses (2001, hereby referred to as the ANA Code). The third provision of the ANA Code is “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” The act of mandatory reporting is not equivalent to protection of the safety of the patient. Mandatory reporting relies on the support and cooperation of police and services agencies to ensure the safety of individual patients. However, as Sullivan and Hagen (2005), found in their study of 61 survivors of sexual assault, the perpetrator of abuse in an intimate relationship is often a member
of the law enforcement agency himself. This poses a dilemma when discussing safety of victims of IPV. While the mission of police departments as a whole may be to protect all citizens equally, individual bias may have an impact on the execution of police action. Autonomy Autonomy is the right to self-determination which was briefly discussed above. In order to support a patient’s autonomy, nurses are responsible for presenting patients with all available and pertinent information and resources; only then can the patient freely choose for herself or himself which option is best for her or him as an individual (Harkreader & Hogan, 2004). Mandatory reporting of IPV injuries in an adult patient clearly violates the principle of patient autonomy by denying the individual to choose a “treatment.” There are several studies which measure patient’s attitudes towards mandatory reporting. The largest, a 1999 telephone survey which interviewed 845 women in 11 different cities found that while 73% of non-abused women supported mandatory reporting laws, only 59% of abused women supported them. However, it should be noted that 76% of respondents said that “victims would be less likely to disclose abuse and would resent someone else having control” (Sachs, Koziol-McLain, Glass, Webster, & Campbell, 2002, p. 126). If individual women feel that mandatory reporting laws would deter women from reporting, how can these laws accomplish any of the effects proponents of the laws think they will? If victims do not disclose IPV to their health care providers, they will not be identified, their perpetrators will not be prosecuted, intervention will not be possible, and data collection will decrease. Other, smaller, studies consistently demonstrate that patients do not support mandatory reporting laws. Rodriguez, Sheldon, and Rao (2002) interviewed 358 abused women and found that 68% “did not prefer a domestic violence injury reporting system that was mandatory even if
against patient wishes (p. 136). In Sullivan and Hagen’s (2005) study, 60 out of 61 participants “did not support mandatory reporting by health care providers to the police until a number of system-level changes have occurred” (p. 350); it is important to note that the 1 participant who supported the laws was a victim of stranger rape. These studies further support the position that mandatory reporting laws violate patient autonomy because abused women themselves do not want their cases to be reported to police against their will. Confidentiality Every client has a right to privacy of the information she or he discloses to a health care provider. Every client should be informed that any information recorded may become part of a medical record that may be available to other health care providers (Harkreader & Hogan, 2004). This may or may not affect the information that a patient chooses to share with a nurse. The maintenance of confidentiality is based in the principle of respect for human rights as outlined in the ICN Code. Mandatory reporting of IPV injuries in adults is a basic and gross violation of a patient’s right to confidentiality. A patient may or may not be aware of mandatory reporting laws before disclosing information about IPV. These laws violate not only the confidential atmosphere of the doctor’s office, hospital room, etc., but the trust in the nurse-client relationship as well. Nonmaleficence The term nonmaleficence as it is applied to the nursing profession means to do no harm (Harkreader & Hogan, 2004). The major way that mandatory reporting violates the principle of nonmaleficence is by possibly causing further violence against a victim of IPV. Sachs et al. (2002) found that 44% of abused women felt that mandatory reporting might increase risk for injury. When a patient chooses to share information about abuse within a relationship, she may
or may not want help; she may not be in a position to leave her abuser due to economic abuse, physical disabilities, love for her abuser despite the violence, and/or a myriad of other reasons. In fact, leaving an abusive relationship or seeking protection from an abusive partner from the police may prompt further abuse. Nurses need to know that they themselves are not causing the violence their patients may be experiencing. By screening, they are not causing harm to their patients; but reporting IPV to police may cause retaliatory violence by an abuser. Mandatory reporting laws place the responsibility of a patient’s safety on health care providers but rely on the services of the police and courts to execute safety plans for these victims (Lewis-O’Connor, 2004; Sullivan & Hagen, 2005). It cannot be assumed that the police will be efficient or effective in serving the victims of IPV. In a letter to the editor of the Journal of Emergency Nursing, Jezierski, Eickholt, and McGee (1999) respond to a research column by Koziol-McLain (1998) scolding nurses for not reporting IPV as often as they should: It is not unusual for an arrest to be made and for the perpetrator to be released from jail within hours or the next day. How much sense does it make to mandate reporting if a system is not in place to ensure survivor safety and perpetrator accountability? (¶ 3). In addition, Sachs et al. (2002) found in their study that survivors opposed to mandatory reporting noted inconsistent police response in combination with increased agitation of the abuser as reasons for opposing the laws. Mandatory reporting laws falsely assume that police departments are actively working towards an end to IPV; this assumption may be deadly for women forced to report incidents of IPV to police. A Feminist Approach: Nurse Education, Routine Screening, and Patient Advocacy Because, according to Silva and Ludwick (2002), “ethical codes demand social action” (¶
18), and because mandatory reporting is ethically immoral, nurses are faced with a dilemma about what exactly they should do when faced with issues of IPV. And because “providers and patients alike are leery of the intervention of courts and social service agencies (LewisO’Connor, 2004, ¶ 10) nurses are further faced with the problem of what to do when the available services do not necessarily serve their patients’ individual needs for safety. Feminist ethics assert “that systematic and ongoing oppression of women based primarily on gender is morally wrong” (Lewis-O’Connor, 2002, ¶ 2). A feminist approach to the problem of IPV as it presents in a health care setting includes three basic features: education for all nurses about IPV and how it works, routine screening of all women ages 14 and above, and patient advocacy for patients experiencing abuse. The following approach ensures patients’ rights to respect, autonomy, confidentiality and nonmaleficence. Nurse education. The suggestions for system improvement made by the participants in Sullivan and Hagen’s (2005) study revolved around increased training for providers. Education for nurses about the tactics of abuse will help to give nurses insight into the types of experiences abused patients may be experiencing in addition to physical or sexual violence. Education about verbal and economic abuse may help to clarify misconceptions about reasons victims have for staying with an abuser. Educating nurses about barriers victims face when trying to leave abusive partners will help them understand the myriad of resources victims need to ensure their safety and well-being when trying to leave or live safely. In addition, educating nurses about patient autonomy and IPV may help nurses to better respect the decision of a victim to stay with an abuser, and at the same time connect a patient with resources that can help her to stay safe. Routine Screening
Several researches make a call for IPV screening (Jezierski, Eickholt, & McGee, 1999; Silva & Ludwick, 2002; Sullivan & Hagen, 2005). The participants in Sullivan and Hagen’s (2005) study explicitly supported having their health care providers asking their patients if they are experiencing or ever have experienced abuse. While screening may not put an end to abuse, when patients disclose to providers who have been properly trained to respond to victims of IPV, their feelings will be validated and they will be referred to agencies that can offer them services to assist them in ensuring their safety and wellbeing. In addition to identifying IPV, screening practices starting at an early age create an opportunity for patient education and prevention of violence in relationships. Patient Advocacy Patient advocacy has already been discussed in the two preceding sections. Nurses can advocate for patients by assessing their needs and referring them to the appropriate agencies, making calls for their patients if necessary. Nurses can also advocate for their patients by discouraging their legislators from passing mandatory reporting laws. Because feminist ethics support empowerment of women, advocating for a patient encourages that patient to act on her own behalf. What About Children? Often, children and women are being abused by the same person. Nurses cannot assume however, that this is the case when they are caring for a victim of IPV. Lewis (2003) suggests that domestic violence projects and child protective services work together to empower women by screening for both IPV and child abuse, and by informing patients that health care providers are mandatory reporters of child abuse. There is an overarching belief that mothers who fail to protect their children from abuse are completely incompetent as parents. However Lewis (2003)
“found no evidence that abused mothers are less affectionate, less protective, less likely to provide structure, or more punitive or physically abusive” (p. 356) than mothers who are not abused by their partners. Nurses must be aware of these findings in order to dispel any bias that they may have towards these patients. Conclusion Intimate partner violence poses a serious risk to the health of millions and nurses must demand institution and government cooperation in promoting screening and discouraging mandatory reporting policies. Mandatory reporting of IPV injury may cause a victim to incur further violence at the hands of her abuser, violating the ethical principle of nonmaleficence. These laws further violate the rights of patient autonomy, confidentiality, and the human right to be treated with respect. Nurses can fulfill their ethical duties to their patients by educating themselves on these issues, routinely screening their patients, and advocating for the victims and survivors of IPV.
References
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