An ethical approach to racial disparities in child abuse medicine

Black, Hispanic, and Native American children are more likely to be evaluated and reported for suspected abuse despite evidence that race does not independently change their risk of maltreatment. Once reported to Child Protective Services (CPS), these children and families are exposed to a child welfare apparatus fraught with inequity and systemic racism. Pediatric healthcare providers responsible for evaluating and treating injured and neglected children act as de facto gatekeepers to this unequal system. They must balance the risks of missing abuse with the consequences of CPS involvement. Ethical guidance with which providers can navigate this conflict is sparse and fails to adequately account for systemic racism and disproportionality.

We aim to examine the ethical challenge facing pediatric healthcare providers who assess for and report suspected child abuse. We begin with a review of racial disproportionality in the evaluation of suspected abuse and a summary of the harms faced by families exposed to the child welfare system unnecessarily. Then, we discuss empiric research on mandated reporting behaviors and the indeterminacy of “reasonable suspicion” as a universal standard. Finally, we propose a framework by which child maltreatment prevention can be re-imagined as a two-sided problem wherein providers balance the need to protect children from abuse with a newly recognized obligation to shield families and communities from an unjust child welfare system.

Genevieve Preer, MD – Medical Coordinator Child Protection Team, Pediatrics, Boston Medical Center; Caroline Kistin, MD, MSc – Associate Professor, Health Services, Policy, and Practice, Hassenfeld Child Health Innovation Institute, Brown University School of Public Health