Ethical Question - MMI Scenario (Cultural Practices)

[Butterfly_]

You are a GP and a mother comes into your office with her child who has flu like symptoms. You notice bruises on the child’s torso and the mother tells you that it is a procedure called cao goo, to raise bad blood, improve circulation and healing. You touch the boy’s back with your stethoscope and he winces in pain. Should you call Child Protective Services and report the mother? When should a physician step in to stop a cultural practice? Should a physician be concerned about alienating the mother and people of her ethnicity from modern medicine?

Here’s my attempt at trying to answer the above. Any comments and advice would be greatly appreciated. Thank you!!

 

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I understand that as a physician, I have a duty to protect children from harm and to report child abuse. However, at the same time, I also need to respect another persons culture and ensure hat my actions don’t alienate people of certain ethnicities. In the scenario here,the mother voluntarily brought her child to the clinic knowing her child would be examined and was very forthcoming in her explanation. Also, the mother performed the procedure to improve the well-being of her child. Therefore, there seems to be no ill intention. 

To further investigate, I would speak to the child directly and ask about the bruises, whether or not he has had the procedure before as well as how he is feeling. If he says the bruises don’t bother him much and the procedure actually made him feel better than before and he has good rapport with his mother, then I would not call child protective services.

Howver, if the child appears to be afraid of his mother and is in a lot of pain from the procedure, then a call to Child Protective Services would be warranted.

Physicians should step in to stop a cultural practice when it is endangering the health and safety of their patients. Even if this alienates people of certain ethnicities from modern medicine.

In conclusion, before making any decision to call Child Protective Services, I must make sure to gather sufficient information on the cultural procedure performed, understand the relationship between the parent and child, and evaluate the child’s physical and emotional well-being.

 

 

[insomnias]

I know you're generally not supposed to be categorical in MMIs, but I'm pretty sure I'd call CPS on this one lol. Good thing I'm employable if I don't get into med

(But in an MMI, of course, you can always say that you'd educate the patient's parent and let them know that this isn't generally something we do in Canada, and, judging by the child's response to your touch, it may have hurt more than it helped)

[Butterfly_]

3 minutes ago, insomnias said:

I know you're generally not supposed to be categorical in MMIs, but I'm pretty sure I'd call CPS on this one lol. Good thing I'm employable if I don't get into med

(But in an MMI, of course, you can always say that you'd educate the patient's parent and let them know that this isn't generally something we do in Canada, and, judging by the child's response to your touch, it may have hurt more than it helped)

You do raise very valid points! I think i would have done the same if I haven’t gone through almost the same procedure personally.

As a kid, I went to an acupuncturist who would light candle in a glass jar then put it on my back, creating suction to draw out bad blood, pretty similar to this mmi question. It would hurt, but afterwards I did feel better.

If a doctor called the CPS on my parents, I would have been shocked. 

I find this mmi question so difficult =\

[hartk48]

Bare in mind that I not a successful candidate at the moment, but I did practice quite a bit... so take my response with a grain of salt. I am 100% open for criticism! 

I would explicitly say that CPS is an option, but after I exhausted all my options.

Points that I would make in my arugment

- talk to the child as mentioned earlier

- talk to the parent and try to educate them, while paying attention to their attitude - if the parents are responsive and positive, this will keep me away from calling CPS

-asking them if the frequency of this healing procedure can be decreased or if we can talk to some community leader to see if he or she can give the parent an exception

-ask for follow ups to make sure the child is improving (after all they came for you due to the flu, dont forget that)

 

To answer the three questions you were explicitly asked (while integrating it to the above points) I would say:

- call CPS if all above fails and the child's condition worsens upon follow up 

- stop a cultural practice if it has a direct harm on someone that can not advocate for them self (usually incompetent individuals)

-The physician should absolutely be concerned about alienating a group of individuals, which is why such precautionary measures should be taken. Had CPS were called immediately, trust between future patients and the medical establishment can be broken - hindering the care of many people. 

[Butterfly_]

54 minutes ago, hartk48 said:

Bare in mind that I not a successful candidate at the moment, but I did practice quite a bit... so take my response with a grain of salt. I am 100% open for criticism! 

I would explicitly say that CPS is an option, but after I exhausted all my options.

Points that I would make in my arugment

- talk to the child as mentioned earlier

- talk to the parent and try to educate them, while paying attention to their attitude - if the parents are responsive and positive, this will keep me away from calling CPS

-asking them if the frequency of this healing procedure can be decreased or if we can talk to some community leader to see if he or she can give the parent an exception

-ask for follow ups to make sure the child is improving (after all they came for you due to the flu, dont forget that)

 

To answer the three questions you were explicitly asked (while integrating it to the above points) I would say:

- call CPS if all above fails and the child's condition worsens upon follow up 

- stop a cultural practice if it has a direct harm on someone that can not advocate for them self (usually incompetent individuals)

-The physician should absolutely be concerned about alienating a group of individuals, which is why such precautionary measures should be taken. Had CPS were called immediately, trust between future patients and the medical establishment can be broken - hindering the care of many people. 

Thank you!

[vellichor]

I would wonder about the risks/consequences of calling CPS in and of itself when it’s not an obvious situation of child abuse. Especially when it comes to demographics that historically and currently have had extremely bad blood (joke unintended) with the government/foster care system- see: sixties scoop, current issues with Indigenous youth in care... is a culturally appropriate treatment that causes minor discomfort/pain to a child sufficient reason for starting the process that would potentially subject that child to the trauma involved in being taken away from their family (which, imo, would probably cause significantly longer lasting psychological harm)? Especially considering that Canada allows corporal punishment- which has negative consequences in and of itself, but we allow it because of believing in the rights of the parent to decide what’s best for their children. How does that differ from culturally appropriate treatments that don’t involve lasting harm to the child and might actually help them feel better overall? 

Might be a little off-topic MMI-wise but it’s an interesting issue. Personally I /definitely/ wouldn’t jump the gun and call CPS immediately, if anything I’d want to ask more about how common the procedure is in this culture, whether the child is okay with it, any evidence of efficacy, any negative effects of the treatment, etc. 

 

 

edited to add: i wouldn’t base a decision on whether to call/not call on how friendly (aka “responsive and positive”) the parents seem to you, since previous negative interactions with the healthcare system might have made a parent wary of you- I’d look more at how they’re interacting with the child, and whether /that/ particular interaction is positive, not the one between them and you as a physician. 

[rmorelan]

this one I think touches on some interesting ethical issues - the only problem is I believe there are actual rules about this sort of thing. If you suspect there is even a possibility of abuse you have to call CPS. They are the ones that decide whether something is a normal cultural practice or a form of abuse (or rarely that can be the same thing by our rules). It is not the job of a health care worker to make that determination. The trouble is we have had people hide abuse in all manner of ways so we have strict rules to protection those that have no other way to protect themselves. In short we are extremely cautious. 

Now like all ethical problems it doesn't mean you stop there - doing all the questioning and searching is important as well. That would help inform the debate. Plus people CPS is not a necessarily a neutral option as an investigation is invasive at times.  However in Canada that all has nothing to do with whether you would call CPS.

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If you have reasonable grounds to suspect a child is in need of help, you need to make the call. It isn’t up to you to prove or investigate the abuse but it is up to you to reach out and help protect the child. (this is my main point - you aren't supposed to be the one that does the investigating - if you have reasonable grounds to start asking questions the you are already suppose to contact CPS. A child that is wincing in pain with touch I would argue meets the reasonable person test )

Under section 72 of the Child and Family Services Act every person who has reasonable grounds to suspect that a child is or may be in need of protection must promptly report the suspicion and the information upon which it is based to a Children’s Aid Society. This includes persons who perform professional or official duties with respect to children, such as health care workers, teachers, operators or employees of child care programs or centres, police and lawyers.

It is not necessary to be certain that a child is or may be in need of protection to make a report to a children’s aid society. “Reasonable grounds” refers to the information that an average person, using normal and honest judgment, would need in order to decide to report. This standard has been recognized by courts in Ontario as establishing a low threshold for reporting. The role of the Children’s Aid Societies is to investigate calls made by the public using a professional and standardized process. The person making the report should bring forward their concerns and Children’s Aid will determine if there is a sufficient basis to warrant further assessment of the concerns about the child.

[Butterfly_]

On 2018-02-23 at 9:44 PM, vellichor said:

I would wonder about the risks/consequences of calling CPS in and of itself when it’s not an obvious situation of child abuse. Especially when it comes to demographics that historically and currently have had extremely bad blood (joke unintended) with the government/foster care system- see: sixties scoop, current issues with Indigenous youth in care... is a culturally appropriate treatment that causes minor discomfort/pain to a child sufficient reason for starting the process that would potentially subject that child to the trauma involved in being taken away from their family (which, imo, would probably cause significantly longer lasting psychological harm)? Especially considering that Canada allows corporal punishment- which has negative consequences in and of itself, but we allow it because of believing in the rights of the parent to decide what’s best for their children. How does that differ from culturally appropriate treatments that don’t involve lasting harm to the child and might actually help them feel better overall? 

Yes, I agree with this. 

A little off topic, but Children’s Aid has been riddled with problems. Many children in foster care die or get abused. Personally, I think many children are worse off with them. 

It’s a tragic situation.

Back to the question, At the end of the day, I won’t call CPS if the mother-child interaction seems fine and the child is not fearful or in lots of pain. Wincing from a bruise is pretty normal. If I fell and someone pressed on my bruise, as an adult, I’d wince too, let alone a child. Also, if it’s a real case of child abuse, wouldn’t the mother want to hide the bruises better or hurt in areas less visible to a doctor? I would educate the mother on alternative ways to treat her child or aid circulation. If on the next visit, I still see the child with bruises, then that would warrant a call to CPS. Calling CPS on a family is devasting to the parents and children. And based on only one visit, it’s a hasty decision. It also destroys the physician-patient relationship if the doctor is wrong. There was a case on the news last year where a doctor wrongfully called CPS on the mother. Just horrifying. 

[dumbebell]

Hey I would check videos on youtube for similar questions *not sure if I am allowed to link them here*

Key here is to go step by step i.e. take baby steps! You definitely don't want to 'jump' on your answers. I noticed that in MMI, its not the answer itself that matter most, it is the critical skills of attempting to look at problems via multifaceted manners so critical skills are highly important.

[Pipiquedued]

Hello,

check out this paper . It outlines Cao Gio specifically, and gives some guidelines in balancing cultural sensitivity and human rights.

From the linked article= to determine if something is indeed abuse they list 4 items to consider. (again read article for more in depth) p. 241

1. Child discloses that there is a perceived injury/negative psychological consequence of practice

2. Child judges that the benefits do not out weigh the cost (ie physical/psychological pain is too high when compared to outcome)

3. Parent's intent versus actual outcome

4. Lack of supporting evidence for effectiveness of practice.

 

For each point:

1+2 Discuss with the child the amount of pain they experience, and then if child expresses a large pain amount, discuss with parent if there are levels to the treatment, perhaps they can do it less often or to a lesser extent. I would encourage that they discuss options with someone else familiar with the practice.  I would also ask if the child agrees with the treatment, and how they perceive it.

3 It sounds likes the parents intent is good. As they were forth right in answering, and explained the perceived benefits they were attempting to achieve. And the perceived outcome is considered good as well.

4 In the case of Cao Gio, it is a very established practice, practiced in the Vietnamese medical community, and evidence does show that it is effective in treating many ailments.  

 

Overall, in this case, this is not child abuse.
I would record the observation and the discussion that was had. I would be aware that I do not want to be accusing in my tone, but rather inquisitive. In follow up visits I would continue to make observations to see if the bruising continues, worsen, and the state of the child's attitude towards the practice.  Being accepting of ones cultural practice does not give a free pass to abuse and so I would still need to be diligent that the practice is being conducted with "appropriate use within the culture" p. 237.

 

https://files.eric.ed.gov/fulltext/EJ651688.pdf