Letters

Disclosure of child sexual abuse

BMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7152.208 (Published 18 July 1998) Cite this as: BMJ 1998;317:208

Maintaining confidentiality is not in best interest of woman or others

  1. B Harrington, Lecturer in child health.a
  1. Department of Child Health, St Mary's Hospital, Manchester M13 OJH
  2. a Professor David is Head of the academic department to which I belong. I have not discussed the case, or this letter, with him.
  3. Dudley Priority Health NHS Trust, Department of Psychiatry, Bushey Fields Hospital, Dudley, West Midlands DY1 2LZ

    EDITORmdashIn the recent ethical debate on child sexual abuse an allegation of a serious criminal offence was made in a situation of assumed confidentiality.1 Revealed child abuse (physical or sexual) is rarely an isolated occurrence, and perpetrators tend to escalate their activities with time.2 Sexual abuse of children is a personality disorder which does not spontaneously resolve and is refractory to intervention.3If these allegations are true, other children may have been or may still be being abused.

    Medical training inculcates an ability to make decisions. This can create an expectation of making a decision when it may be inappropriate for the decision to be made by an individual doctor. A fundamental tenet of child abuse work is to share information. Indeed, the Children Act makes this a duty.4One person may be unaware of all the information. David is not in a position to make a decision not to proceed. Immediate medical and social work colleagues would be his first points of reference and, thereafter, the trust's medical director (who will have access to legal advice) and his defence society.

    If abuse to others occurred after the date of this woman's disclosure and was uncovered and it then became known that David had had this information, it is not certain how a judge or the General Medical Council would regard a choice of maintaining confidentiality. Would a victim be able to sue the professor for placing confidentiality ahead of a future victim's physical and psychological safety?

    What of the woman's best interests? It is difficult to take life decisions which are for the best in the long term but which will precipitate extreme short term difficulties. She has bulimia, and the prospects of resolving this without addressing the underlying psychodynamics are poor. Her main obstacle to disclosure is the real fear of further psychological difficulties. Victims of child abuse need help in coming to full disclosure. Did David inform her of the support and therapeutic options which could help her to cope and recover after disclosure?

    He should meet this woman again to see if she has altered her views. If she has not, he should explain why he has to make disclosure. He should tell her how he intends to address her needs and liaise with her general practitioner.

    References

    Doctor has duty to warn others

    1. P Cullen, Consultant psychiatrist.
    1. Department of Child Health, St Mary's Hospital, Manchester M13 OJH
    2. a Professor David is Head of the academic department to which I belong. I have not discussed the case, or this letter, with him.
    3. Dudley Priority Health NHS Trust, Department of Psychiatry, Bushey Fields Hospital, Dudley, West Midlands DY1 2LZ

      EDITOR–David describes a case which should be of interest to all doctors and people in positions of trust.1 Disclosure of sexual abuse experienced as a child may occur at any time but is more likely in a safe setting with trusted individuals. Given that doctors in general are still seen as among the most trusted in society, disclosure might occur with any doctor, independent of issues such as whether a therapeutic relationship exists.1

      The argument is not whether it is the duty to patient or society that is paramount but how best to fulfill our duties to both. I would proceed by having a further detailed discussion with the woman concerned on the dilemma her disclosure has presented to me. The discussion would include dealing with the issue of a duty to warn others. This duty has been established in the United States for physical threat2 and the broader implications for the United Kingdom have recently been described.3 I would also want to share with her that it would probably be necessary to contact other agencies with a view to safeguarding other children. I would thus hope to sway her to agree to further action, which could be anonymous.

      I believe that the basic principles of ethics would be satisfied by this approach. Autonomy is achieved by giving the woman the opportunity to discuss fully her situation as well as the effects of disclosure in an open, adult manner. Beneficence and non-maleficence are upheld by ensuring that the woman is at least offered counselling and professionally advised on the decision about possible prevention of future abuse by the abuser. Justice might then be done in that the abused, the abuser, and society are dealt with fairly.

      References

      1. 5.
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      3. 7.