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As we discussed in part 1, the problem with the term “Munchausen syndrome by proxy” is that it diagnoses the parent rather than the child. It puts the focus on a mental illness rather than a crime. And it puts medical professionals and lay people alike in the untenable role of playing armchair psychiatrist, forcing them to make judgments that are not qualified to make.
Shifting the focus to medical child abuse encourages an objective, evidence-based approach to either confirm – or disconfirm – suspicions. Is a parent repeatedly telling others about a child’s diagnosed illness even medical records document that this disorder has been ruled out (and that the parent have been told this)? Is a parent insisting a child be fed through a tube in his stomach yet others witness the child eat food normally? Does a child’s health consistently improve when visiting a grandparent or relative and quickly deteriorate when back in the home? Do the hospitalized child’s symptoms only appear during or shortly after the primary caretaker has been to visit?
These are the kinds of questions investigators need to answer – not whether there is a deep-seated, malignant motive behind a parent’s disagreement with his or her physician or a quarrel over a child’s diagnosis.
What Does “Do No Harm” Mean?
Physicians have many responsibilities, especially when treating children. One of these is maintaining a good rapport with parents; in fact, parents are generally a physician’s best ally in the fight for a child's good health. Pediatricians rely on and trust caretakers to accurately report a child’s symptoms and to administer prescribed treatments, just as parents rely on their child's doctor to help him or her get better. Few pediatricians take this relationship lightly; erroneously questioning a parent’s motive or intent can seriously disrupt the treatment relationship and remove a vulnerable and ill child from his or her primary source of love or support.
Having said that, let’s look at the potential consequences of a pediatrician failing to report suspected medical child abuse. Victims often undergo unnecessary surgical procedures, painful diagnostic tests, or medical interventions to treat these fabricated, exaggerated or nonexistent symptoms. Consider the untold amount of psychological trauma involved in a life that unnecessarily revolves around hospitals and doctors instead of schools and playdates. In fact, research suggests that medical child abuse victims have a mortality rate (9%) that is similar to bacterial meningitis sufferers or anorexia nervosa patients, underscoring the need for multidisciplinary action should the need arise.
Physicians must be able to view a patient through a lens of objectivity, and when the objective findings don’t match what a parent describes, to consider all possibilities; a parent who is worried about a chronic, minor illness, a child whose unexplained symptoms have yet to receive an accurate diagnosis, or – rarely – that what a parent is saying is not true.
The Bottom Line
Pediatricians have a responsibility to educate themselves on uncommon childhood diseases, to doggedly pursue accurate diagnoses for patients with unexplained symptoms, and to communicate effectively with parents and other treating professionals so that miscommunications or personality clashes don’t cloud the diagnostic picture. But ignoring the possible existence of a deadly form of abuse in order to avoid offending parents or to minimize the risk of being sued isn’t the answer. A child’s life could be at stake.
