About a year ago there was a commentary in the Journal of the American Medical Association that sparked controversy by suggesting that in some cases, severe childhood obesity could justify state intervention on behalf of the child. The commentary received quite a bit of media attention and the online comment boards lit up with very passionate opinions on both sides of the issue.
On one side of the issue are those who argue that extreme childhood obesity is a form of parental neglect, analogous to malnourishment, and intervention is warranted to protect that child from harm. On the other side of the issue are those who argue that obesity is more complicated than malnourishment as there may be various factors at play, and intervention puts blame on parents for something that may be out of their control. I wanted to use this topic to discuss the broader ethical and professional issue of reporting potential harm and along the way I will make some observations about the particular issue of reporting childhood obesity.
An appreciation for the issue of reporting potential harm begins with the foundation of the therapeutic relationship: trust. Your patients or clients must be able to trust you as a professional – in particular to trust that you will promote their well-being and respect their privacy by maintaining confidentiality. Without that trust patients will be reluctant to seek healthcare and will be less forthcoming with the information they share with you when they do.
Sometimes, however, you will become aware of situations that pose a potential risk of harm to an individual or group. Thus the ethical issue: you know you’re supposed to maintain confidentiality and avoid damaging the therapeutic trust, but you also know that you have a responsibility to prevent harm. The ethical consensus we have reached in our society is that you are justified (and in some cases obligated) to violate confidentiality and report the potential harm when the risk of harm is serious, imminent, the threat is realistic, and reporting is likely to be successful at preventing the harm. For example, the College of
Physicians and Surgeons of Ontario policy #3-05: Mandatory Reporting, lists the various situations in which Ontario physicians are obligated to report potential harm. In these situations the risk of harm outweighs the potential damage to the therapeutic relationship.
One situation that obligates health care professionals to report potential harm is suspected child abuse or neglect. The legal basis for this obligation is our Child and Family Services Act (RSO 1990), which is legislation that was put in place to protect vulnerable children from harm. The Act obligates all persons with “professional or official duties with respect to children,” to report reasonable suspicion of a number of different kinds of potential harm toward children to the appropriate child welfare agency. The kinds of harm include physical abuse, sexual molestation or exploitation, required medical treatment to which the parent or guardian is refusing to consent, emotional harm caused by neglect, and so on. Malnutrition very clearly fits into these categories: the child is suffering, or is very likely to suffer, serious harm as a result of malnutrition. Such malnutrition is either directly caused by parental neglect or abuse or it may have a physiological cause, in which case a care plan will be proposed to the parents or guardians for consent.
Obesity is a bit more complicated, however, for several reasons. First, the potential harm typically won’t be imminent, unlike a child who is severely malnourished and is at imminent risk of life-threatening complications. The health risks of severe obesity for children won’t typically manifest themselves until later in life, when the child begins to experience complications from diabetes or heart disease. Second, there are socioeconomic factors that contribute to obesity: healthy food is considerably more expensive than unhealthy food, and even organized sports for children can be very costly. Third, there isn’t a clearly defined medical intervention for obesity like there is for typical cases of severe malnutrition (admission to hospital with oral or artificial re-feeding). Treatment for severe obesity may include a variety of interventions, such as dietary modification, an exercise program, and counseling or therapy.
Given the above, it is highly unlikely that a typical case of childhood obesity would warrant reporting to the appropriate child welfare agency. That said, there may be extreme cases where reporting would be the right thing to do. These would be situations of severe obesity where the potential harm is more clearly imminent and the parents have demonstrated a lack of ability to help the child themselves through lifestyle changes. Such cases may be analogous to cases of severe malnutrition and would justify reporting the case to a child welfare agency.
One final comment about reporting harm: sometimes there will be situations that don’t clearly fit into a mandatory reporting category. That only means you aren’t legally obligated to report. Reporting may still be the ethical thing to do if the conditions mentioned above are met: the risk of harm is imminent, serious, the threat is realistic, and reporting is likely to prevent the harm.