Mandated Reporters: The Ethical Education of Medical Students on Pediatrics Clerkship

Abstract

Medical students are taught to cherish the ethical mandate to “do no harm.” However, the competency to actualize this mandate – or at least theorize how – is not always available to students on pediatrics clerkship when they encounter situations suspicious for child abuse. Mandated reporter training for medical students is largely perfunctory and does not prepare students to identify or document instances of suspected child abuse. Such training approaches students from the threatening angle that they can face punitive measures if they fail to report suspected abuse. In the absence of more thorough, ethics-driven training, students learn informally about their responsibilities as mandated reporters by observing pediatricians communicate about their own interactions with Child Protective Services (CPS), if the topic arises during clerkship. The theoretical premise of child protection is that all involved parties act in accordance with implicitly understood and shared ethical principles to safeguard the wellbeing of children [3]. Despite this assumption of accord, very little standardization exists throughout the process of identifying and reporting suspected child abuse, with the exception of some specific situations that explicitly require CPS referral. Families of color, especially Black families, are disproportionately reported to CPS for child abuse, revealing a major consequence of subjective bias in assessing parental adequacy [2]. A pediatrician may, for example, misattribute a parent’s confusion about a child’s treatment plan to noncompliance and medical neglect [1]. A CPS referral in such an instance draws a line between the medical treatment team – in the role of benevolent advocate of the child’s wellbeing – and the obstructionist, perhaps abusive parent. The medical student, as part of the treatment team, has proximity to the power-holder in the situation, the physician. The student is incentivized to neglect an ethical obligation to explore whether this dynamic is causing harm to the patient. The student does not learn to interrogate the etiology of challenges faced by the parent, or to consider that CPS involvement itself may have deleterious effects on the family [4]. A more intentional and expansive approach to the ethics of mandated reporting throughout medical school would better prepare students to understand and exercise ethical judgment.