Several recent graduates of unrelated child and adolescent psychiatry (CAP) residency training programs sent in questions, seeking feedback from the Ethics Committee (EC), regarding similar uncomfortable situations that they and their co-residents had experienced during their training. A conflated case will serve as an example.

This is the third in a series of ethics cases presented in AACAP News. As suggested previously, please read the case, then stop. Spend a couple of minutes to think about your response. Resume reading, and review a compilation of the sentiments of the EC members.

Case: Dr. Smith, a CAP resident, has been treating a 15-year-old girl, diagnosed with depression, for the past year. The treatment is taking place at a CMHC affiliated with a medical school that services a large, urban, inner-city population. The girl’s mother, diagnosed with schizophrenia, has been briefly hospitalized twice in the prior five years to treat acute psychotic episodes. The girl and her nine- and seven-year-old siblings have always lived with their mother as a close-knit foursome; mother lives in isolated fashion in the home while the children attend school. During the two episodes the children lived with an elderly aunt, their only known relative, who made it clear to them that they were not welcome in her home. The girl’s mother receives her outpatient care at the adult clinic housed in the same building as the daughter’s clinic.

On the day of her regularly scheduled appointment, the girl informs Dr. Smith that the mother, several days before, in a state of agitation and while hallucinating, had twice swiped at her with a knife and inflicted superficial lacerations. The girl and her siblings, based on their prior experiences, successfully “pacified” their mother. The acute episode subsided over 72 hours, without extra-familial communication, knowledge, input, or intervention. The home, for the past 48 hours, is functioning as it had prior to the incident.

Dr. Smith discussed the matter with her supervisor, the clinic administrator, shortly after the appointment with her patient ended. Dr. Smith, concerned about her patient’s and the younger siblings’ safety, and aware of the state law mandating reports of suspicions of abuse and/or neglect, stated her intention to inform the state’s Child Protective Services (CPS) agency about the recent events. The supervisor definitively and specifically told her not to do so, explaining that such a call would likely damage or disrupt the existing therapeutic alliances with both the girl and her mother and could well lead, in addition, to the separation of the family members who are essentially each other’s sole family supports. Further, the supervisor mentioned that the state CPS agency was currently experiencing intense political pressure to remove children with “the slightest whiff” of potential danger in the home, given its failure to do so in several high profile cases that ended disastrously. At the supervisor’s urging, the resident discussed the case with the mother’s treating physician, who similarly urged no contact with the CPS agency. The entire experience left the resident feeling confused, angry, betrayed, and impotent.

The residents ask the following questions:
1. Does reporting cases to CPS require a supervisor’s approval? 2. Where does “loyalty to an institution” come into play? 3. What are the ethical obligations of the resident to children at risk? Can ethical and legal obligations conflict? 4. If they do, which ones prevail? 5. How should a resident handle the subordinate role? 6. Which professional(s) bear ultimate ethical and legal responsibility for their actions?

Response: It’s not easy to be a resident. There is much to learn, patients and supervisors to please, skills to gain, and all amidst pressure and sleep deprivation. The experience can be a painful process for the resident’s body, mind, and soul. Gaining experience cannot be hurried, and learning is likely to include the discovery that one person’s black and white is, for another, rather a shade of gray. This knowledge is acquired while dealing with major and scary concerns, sometimes those that touch literally on life and death issues.

The above case is one such example. Essentially the case boils down to, respectively, concerns about patient safety and the supervisor-supervisee relationship. With regard to the latter the resident may view himself or herself at a power relationship disadvantage. Should a resident choose to disregard the advice/demand of a supervisor, particularly in a case likely to engender intradepartmental angst and publicity, the resident might legitimately expect to be viewed as a troublemaker, defiant, and “unwilling to learn.” Consequences for the resident could lead to poor or non-supportive recommendations and possibly the need for transfer to another program to complete training.

The AACAP EC has 19 members. It is interesting to note that only seven members initially commented on this case (one ringer, Christopher Thomas, M.D., chair of AACAP’s Legal Affairs committee, did so by invitation as well), and later, two more comments arrived. Of these 10 responders, seven felt it ethically imperative to report (one weakly), one supported not reporting, and two were neutral. I suspect that the “gray area” difficulties posed by the case led to an avoidant response by the rest. For the majority patient safety was the dominant issue, and they thought it most likely that safety would be ensured by referral to the CPS. As William Klykylo, M.D., graphically put it: “It is more likely that a family reunion would occur after an intervention than after a homicide.” From that perspective it was ethically incumbent to report the case to CPS. In addition, though proferred as a separate consideration, the legal imperative was voiced by some, i.e., the law does not permit leeway. It states one MUST report. Specters were raised of the potential for incurring considerable liability were a legally mandated report not made, and one respondent commented: “It is wrong for a supervisor to urge a resident to break the law.”

However, another respondent astutely noted that many significant flaws in a state’s ostensible child protection system may be clearly evident to some clinicians, e.g., resulting in the exposure of children put into foster care to an increased likelihood of sexual abuse, family breakup, and inadequate monitoring. Thus, “not reporting this case to CPS is a reasonable decision.” I would guess that the varied opinions represented in the responders’ comments, and the loud silence of the non-responders, at least in part signify the varying and possibly highly contrasting experiences that different CAPs have had with a variety of state child protective service agencies. While the ethical obligation does exist to advocate for change by working within malfunctioning CPS systems, some CAP supervisors/administrators may have experienced severe resistance to those efforts.

Notwithstanding the nuances described above, a summary of the majority response to each of the specific questions are as follows:

1. No. Reporting cases to CPS does not require a supervisor’s approval. BUT, it would be prudent for the trainee to obtain the approval in order to benefit from the wisdom obtainable via discussion, to try to learn to report in a manner that might minimize family disruption, and to not unnecessarily antagonize the supervisor.

2. “Loyalty to an institution” should mean doing the “best thing,” as benefiting the patient would presumably reflect well on the institution.

3. The basic ethical obligation of the resident to children at risk is to do what is best for the child (BENEFICENCE) and to avoid injury (NONMALEFICENCE). Ordinarily, pursuit of these obligations requires a primary focus on the child’s SAFETY, and expending the necessary efforts to ensure it.

4. Ethical and legal obligations may conflict. “Mandated reporting may be one such area” (Christopher Lamps, M.D.). Insofar as ethical obligations are universalizable and overriding, i.e., they hold under all conceivable circumstances and take precedence over personal and group values, adherence to these principles would trump particularistic law. However, non-adherence to law places one in legal jeopardy. Aye, there’s a rub.

5. Residents should handle their subordinate role vis-a-vis supervisors carefully and honestly. Via the course of training, residents need to become aware of matters of nuance in contrast to more simplistic all or none perspectives—they may become more adept at subtleties in the course of learning from supervisors. However, when large material differences of opinion exist, mechanisms should be in place in the training program for those differences to be aired with other faculty. These other faculty could/should include the training director and/or a mentor, assigned to each resident, who does not have a case supervisory role.

6. All the professionals involved in a case, including the residents, share full ethical responsibility for the welfare of the case. The ethical responsibility may differ from the legal responsibility. Trainees share in the latter, but commonly the “deep pockets” principle applies, i.e., legal responsibility and liability will progressively travel up an administrative ladder while including all individuals and entities who have or might have legal responsibility for the resident’s supervision and training.

Many of the responses to the case by EC members contained clear recommendations for training programs. Several members focused on the supervisory process as one intended to promote (mutual) critical thinking and to enhance development of the supervisee’s independence, rather than an opportunity to impose instructed behaviors. Emphasis was also placed on the need of the availability of multiple supervisors for consultation purposes, and the desirability, in complicated cases, of consensus-based decisions. Finally, given that “ethics is the study of observing and resolving conflicting obligations” (Christopher Lamps, M.D.,), and as this case touches squarely on supervisor-supervisee conflicts, this case in particular is recommended for teaching purposes at CAP training programs.