Historically, dating back to ancient times, children have suffered violence (been menaced, maimed and murdered) at the hands of adults (Johnstone 1999b). Today, the abuse of children constitutes one of the world’s most longstanding and tragic public health issues (World Health Organization [WHO] 2002b; WHO & International Society for the Prevention of Child Abuse and Neglect [ISPCAN] 2006). Child abuse continues to occur in epidemic proportions and, despite global efforts to redress it, its incidence and negative impact continues to be largely under-recognised, under-reported and poorly addressed by governments across the globe (WHO 2001b: 2; see also Pinheiro 2006; WHO & ISPCAN 2006). Although child abuse and its adverse effects on the health and wellbeing of children (and the adults they become) are ‘more visible’ today, as noted by the WHO and the International Society for the Prevention of Child Abuse and Neglect (ISPCAN), the degree of this increased visibility ‘is far from sufficient’ (WHO & ISPCAN 2006: 1).

In 1999 the WHO estimated that globally over 40 million children aged 0–14 years suffer from abuse and neglect each year, and require health and social care (WHO 1999). The WHO further estimates that around 53000 children are murdered each year, and that between 73 million boys (7%) and 150 million girls (14%) under the age of 18 years are subjected to some form of sexual violence or forced sexual intercourse each year (WHO 2007a: 1). In some countries, it has been estimated that between 25% and 50% of children suffer severe and frequent physical abuse (including being beaten, kicked or tied up by parents) (WHO & ISPCAN 2006: 11). The burden of ill-health caused by child abuse-related injuries has been calculated to be ‘staggering in terms of cost and socio-economic development’ (WHO 1999). In the United States (US), for example, it has been conservatively estimated that the financial cost of child abuse is around $103.8 billion in value per year (Wang & Holton 2007).

Child maltreatment (literally the ‘wrong handling’ of children) and its harmful consequences can and ought to be prevented (WHO & ISPCAN 2006). As the United Nations (UN) has made clear:

Nurses, like others, have a strong professional, legal and moral obligation to take appropriate action to prevent child maltreatment and the burden of suffering that is so demonstrably associated with it. However, the nature and implications of this obligation requires critical examination in order to improve understanding of the conditions under which it might be held to be binding, and to ensure that it is fulfilled in a manner that genuinely maximises the moral interests of vulnerable children.

Historically, the problem of child maltreatment and protection has prompted a variety of responses at a social, political, legal and professional level (Johnstone 1999b). Notable among these has been the controversial introduction of contemporary mandatory (and permissive) reporting legislation. The introduction of this legislation has had important implications for the nursing profession as a whole as well as for individual nurses.

Today, the mandatory and voluntary reporting of child maltreatment constitutes an important ethical issue for members of the nursing profession, and for authorities formally charged with the legal responsibility of regulating nursing standards and practice. Despite this, the issue has received relatively little attention in the nursing (ethics) literature, and has received even less attention in mainstream child abuse, bioethics, jurisprudence and other related literature (see also Nayda 2002). Of particular concern, and the subject of this chapter, is the lack of attention given to examining the nature and implications of the (professional, legal and moral) obligation of nurses to report child maltreatment, and the ‘special issues’ this obligation may raise for individual members of the nursing profession. It is an important aim of this chapter to redress this oversight, and to identify and address key issues warranting attention by individual nurses, nurse registering authorities, professional nursing organisations, and others who are not nurses but whose work may involve liaison and collaboration with members of the nursing profession.

In the discussion to follow, attention will be given to providing a definition of child abuse, to providing a brief historical overview of the development of the modern child protection movement, to examining why child abuse constitutes a significant moral issue for members of the nursing profession and the community at large, and to addressing some of the key ethical issues raised by mandatory reporting requirements.

Incredibly, up until 1999, there was no internationally recognised operational definition of child abuse (Johnstone 1999b). This situation made the conduct of comparative research and scholarship on the incidence and impact of child abuse (in all its forms) very difficult — a situation that, in turn, added to the complexities of trying to get ‘good information’ about the problem and to inform the development and operationalisation of effective child protection policies and programs (WHO 2002b). Following the publication of a study by ISPCAN (published 2000), in which the definitions of child abuse from 58 countries were compared, this situation changed. In 1999, the WHO Consultation on Child Abuse Prevention drafted the following definition (now recognised as the universal definition of child abuse):

In the process of formulating and adopting this definition, there has also emerged a much greater — and long overdue — appreciation of child abuse constituting an act of violence, which in turn has been defined as:

This shift in thinking and attitude is now seeing a concerted effort, locally and globally, to end violence against children (Pinheiro 2006).

In the US, reported cases of child abuse date back to the 17th century. In 1655, for example, a master was convicted in a Massachusetts’ court and punished for the death of his 12-year-old apprentice (Watkins 1990: 500). Almost 200 years later, in Johnson v State (1840), ‘a Tennessee parent was charged with excessive punishment of a child’ (Watkins 1990: 500). In this case, the court held:

It is also known that in the early 1820s, public authorities in New York recognised their duty to intervene in cases of child abuse (including parental cruelty and gross neglect). This, however, often resulted in children being indentured (i.e. placed into service or an apprenticeship) in conditions as bad or worse than those from which they had originally been removed (Folks 1902, cited in Watkins 1990: 500). The practice of indenture did not fade out until about 1875 following the passage of the 13th Amendment in 1867, which ended not only slavery but ‘involuntary servitude within the USA or any place subject to its jurisdiction’ (Watkins 1990: 500).

Significantly, laws which could be used to protect children from cruelty existed long before the date of the 13th Amendment being passed. As an early commentator on the care of destitute, neglected and delinquent children noted, during the 1800s, ‘laws for the prevention of cruelty to children were considered ample, but it was nobody’s business to enforce the laws’ (Folks 1902, cited in Watkins 1990: 501, emphasis added). Although American ‘state statutes were adopted after 1825 that established a public duty to intervene in cases of cruelty or neglect of children’, these were rarely enforced (Folks 1902; Thomas 1972, cited in Watkins 1990: 501). Further, these statutes stopped short of mandating ‘a responsibility to search out children at risk’ (Watkins 1990: 500). Significantly, it was not until after the landmark (and now legendary) Mary Ellen child abuse case of 1874 (described below) that this situation began to change, largely due to the establishment and development of a formal movement for the protection of children which was initiated as a result of the widespread publicity given to this case. A key feature of this movement was to make it ‘somebody’s business’ to enforce child protection laws.

The North American experience was to be influential in the development of the child protection movement in the United Kingdom, with the first Society for the Prevention of Cruelty to Children in England being established in 1883 and ultimately receiving Queen Victoria’s patronage in 1889 (Fogarty & Sargeant 1989: 17). Like its North American counterparts, this society aimed, among other things, to achieve specific child protection and rescue law reforms, which up until then had failed to be passed. For example, in the 1870s, attempts to introduce anti-cruelty legislation into the English parliament were ‘entirely rebuffed’ with the prime minister of the day, Lord Shaftesbury, defending:

Australia, as a colony of England, was very much influenced by British attitudes and political antipathy in dealing formally with the issue of cruelty to children (Renvoize 1993: 31; Fogarty & Sargeant 1989: 16–17). Of particular interest to this discussion is the situation in the Australian state of Victoria which was not exempt from the problem of child abuse. For example, in 1863, inquests into the deaths of children under 3 years of age found that approximately one-quarter had died as a result of causes ‘denoting neglect, ignorance or maltreatment’ (Gandevia 1978, cited by Goddard 1996: 10). Although child-specific welfare legislation was passed as early as 1864 (the Neglected and Criminal Children’s Act) and a Society for Prevention of Cruelty to Children (modelled on the British society) established in 1897, as Fogarty and Sargeant comment (1989: 16):

A notable example of this antipathy can be found in an argument that was advanced against a proposed Bill introduced into the Victorian parliament in 1891 and which was aimed at ‘making incest a criminal offence’ (Renvoize 1993: 31). In rejecting the passage of the Bill (which was later passed), it was argued ‘that it would be better that a few persons should escape than that such a monstrous clause as this should be placed upon the statute book in this colony’ (Renvoize 1993: 31). Later examples show that this antipathy persisted well into the 20th century. For example, between 1966 and 1968, concern about child maltreatment and protection in Victoria was again highlighted when two medical researchers, publishing in the Australian Medical Journal, recommended the introduction of mandatory reporting laws (Birrell & Birrell 1966, 1968). The government of the day, however, rejected this recommendation on grounds that it would ‘run counter to “welfare ideology” and could lead to hysteria and an urge to punish cruel parents’ (Hiskey 1980, cited in Mendes 1996: 27). In its stead, a system of voluntary reporting was recommended. A decade later, in 1986, a recommendation for mandatory reporting was again opposed by the government of the day, this time on grounds that ‘it was punitive rather than preventive and likely to lead to a large increase in false reports’ (Colyer 1986, cited in Mendes 1996: 27).

Today, the issue of child maltreatment and the need for effective child protection services remains problematic and an ‘endless challenge’ in countries around the world, including Australia. According to the latest figures released by the Australian Institute of Health and Welfare (AIHW), the number of child protection notifications between 1999 and 2005 has more than doubled from 107134 (for the period 1999–2000) to 252831 (for the period 2004–2005), with the number of substantiations also increasing (AIHW 2006: xiii). These figures have been interpreted by some as indicating that an ‘Australian child was harmed, or found likely to be harmed, every 11 minutes in 2004–2005’ (NAPCAN Foundation 2006). Worryingly, Aboriginal and Torres Strait Islander children are conspicuously over-represented in the child protection figures and systems reported.

It has long been evident that ‘the system’ of child protection in Australia — like its overseas counterparts — has not been able to cope with the increase in demands that have constantly been placed upon it. Despite a rise in the reporting of child abuse, significant numbers of children are still maimed and killed each year as a result of abuse received at the hands of their primary carers (AIHW 2006; Strang 1996). A troubling aspect of this scenario is that in Australia, as has been shown to be the case overseas, very often ‘the circumstances leading to the most serious cases of child abuse almost always were known to the authorities, but there was no intervention because no-one would take responsibility’ ( Monash Review 1986: 11, emphasis added). In 1996 these failures of the Australian child protection system were described by one critic as a ‘national tragedy’, and prompted calls by the then Chief Justice of the Family Court, Justice Alastair Nicholson, for the system to be investigated by a royal commission of inquiry (Milburn 1996: 3). This call has, however, been largely ignored at both a social and political level (Johnstone, 1999b, 1999c). Over a decade later, child protection authorities are still quoted in the Australian news media as stating that ‘child protection systems across the country [are] poorly monitored’ (Hannan 2006: 4) and that there is an urgent need for a national non-partisan, sustainable and integrated policy platform in the areas of child development and child protection (Gaughwin 2007: 13).

Important questions remain as to why there is such apathy, at all social, cultural, political and legal levels, to challenge and change the status quo. There are many reasons for this — including, but not limited to: the emotional sensitivities involved, the lack of understanding of the serious long-term health effects of child maltreatment (not to mention its economic costs as well), a lack of awareness of effective prevention strategies, and the ‘pervasive demand for immediate returns on public investments’ (WHO & ISPCAN 2006: viii). What, perhaps, also lies at the basis of this social and political inertia is an even more insidious moral inertia and a culpable lack of moral will to challenge and change the status quo. What will shift this moral inertia remains an open question. What is certain, however, is that this moral malaise will continue until it is recognised and understood that child maltreatment is most profoundly a moral problem and, as such, deserves a sustained and comprehensive moral response.

Child abuse constitutes a significant moral problem and, as such, demands a substantial moral response. Reasons for this are outlined below.

As previously considered in Chapter 3 of this book, it is generally accepted that something involves a (human) moral/ethical problem where it has as its central concern:

Adjunct to these concerns is an additional consideration, namely, that people have a moral responsibility to not cause unnecessary harm to others and, where able, ought to come to the aid of those who are suffering and in distress. As Amato (1990) notes in his Victims and values: a history and a theory of suffering (p 175):

These considerations all apply in the case of child abuse. As can be readily demonstrated, the problem of child abuse fundamentally concerns:

Adjunct to these concerns is an additional consideration involving the moral responsibility people have to not cause unnecessary harm to children and, where able, to come to the aid of children who are suffering and in distress as a result of being maltreated and/or neglected by others.

Underscoring child abuse as a moral problem are a number of other important considerations revolving around the extraordinary vulnerability of children generally. Children are among the most vulnerable members of our community. For the most part, they are unable to protect themselves from the harms imposed on them by people more powerful than themselves. Invariably children have to rely on others for help if their wellbeing and welfare is to be safeguarded. It has long been recognised that without intervention and help offered by others, the abuse and neglect of children rarely stops (Child Protection Victoria 1993: 9; Goddard 1996). Historically, however, children have not always been able to rely on others (including benevolent citizens, health professionals and public officials) to intervene and help them (Johnstone 1999b). Nor have they been able to rely on legal law and its processes. As has been pointed out elsewhere, children have long been considered ‘different’ under law and stand as the ‘paradigmatic group excluded from traditional liberal rights’ otherwise accorded to and protective of autonomous adults (Minow 1990: 283).

Equally troubling, neither have children been able to rely on ethics/morality to protect them. Historically, as in the case of law, ethics has also treated children as ‘different’; specifically, as not deserving the moral respect otherwise accorded to rationally competent adults (usually men) and which, if accorded to children, could have resulted in ‘substantial [and unwanted] intrusion’ into the lives of parents (especially fathers) and guardians (male benefactors) (adapted from Schrag 1995: 357). Because of not being able to rely on others, law or ethics for help, children historically have remained at risk of and have experienced otherwise avoidable harms which, if experienced by adults, would have been (and would be) universally condemned, even by the most rudimentary of moral calculations, as being morally unacceptable.

In light of these and other considerations, it is manifestly evident not only that child abuse is a significant moral problem, but that it warrants a substantial moral response. To be effective this response must include moral initiative and action at an individual, group, community and state/territory level aimed at providing genuine presence (‘being there’) for the children who require the assistance of others in order to get the protection they need from a situation of potential or actual abuse and/or neglect.

In an attempt to redress the historical and legitimated vulnerability of children in the case of child abuse and neglect, governments have responded by enacting either mandatory or voluntary reporting laws obligating certain people (on either legal or moral grounds) to intervene by reporting known or suspected cases of child abuse to child protection services. This response has not been without controversy, however. Pivotal to the controversy have been variant moral beliefs, values and attitudes concerning what constitutes the morally most appropriate response to child abuse given the complexity of overlapping relationships, responsibilities and variant moral calculations that are inherent in any potential or actual child abuse situation. So intense has been this controversy that, in some instances, it has resulted in a significant and serious ‘backlash’ against child protection (see, e.g. Myers 1994).

While there is little disagreement among stakeholders in the child abuse debate that it is morally wrong for children to be harmed unnecessarily and that children should be protected from the harmful behaviours of others, there is considerable disagreement about the kinds of things that can and should be considered bona fide ‘harmful’ to children, the kinds of acknowledged harms that children ought to be formally protected from, and how best to protect children from the harms deemed both bona fide and unacceptable. Thus, while there may appear to be a social consensus about the moral unacceptability of child abuse, quite the reverse may be true. As Lantos (1995: 45) points out, an apparent consensus about child abuse may, paradoxically, ‘mask profound disagreements’ about the nature of child abuse and the apparent responsibilities of various parties (including parents/guardians, health professionals and government authorities) to intervene. Two poignant examples of this can be found in the tragic Australian child abuse cases respectively of Daniel Valerio and Cody Hutchings.

It has been suggested that the ‘failure of the system’ to be convinced of the seriousness of a child’s situation and the need to take protective action rests, in complicated ways, on a prevailing social–cultural ambivalence about violence towards children (Goddard 1996). In support of this claim, it is contended that violence towards children is often viewed, controversially, as being merely ‘discipline’ (and hence socially acceptable) when carried out at the hands of parents/guardians. This is perhaps most evident by the fact that ‘the hitting, punching, kicking or beating’ of children is socially and legally accepted in most countries in the world today and remains a ‘significant phenomenon’ in schools and other institutions (including penal institutions) dealing with young people (WHO 2002b). Although Sweden first outlawed corporal punishment in 1979, and other countries (e.g. Namibia, South Africa, Zimbabwe, Israel) have followed suit (WHO 2002b), and while corporal punishment has been banned in schools in Ethiopia, New Zealand, the Republic of Korea, Thailand and Uganda, currently only 2.4% of the world’s children are ‘legally protected from corporal punishment in all settings’ [emphasis added] (Pinheiro 2006: 12).

In Australia, there has been support at Federal government levels for the use of ‘physical punishment’ of students. The Federal Minister for Education, for example, was reported in 2007 as ‘leaving the door open for a return to physical punishment of students — backing autonomy for school principals to decide on its use’ (Schubert 2007: 1). The Federal Minister for Health was reported as also supporting the idea, stating that while he was not calling ‘for the return of the cane or the strap … there was a case for them’ (Schubert 2007: 1). He was further reported to have argued that ‘a lot of people think that sometimes you’ve got to be able to give [kids] a short, sharp shock’ and ‘it may well be that sometimes the only language that some kids understand is that kind of language’ (Schubert 2007: 1).

There are, however, other possible explanations for why the system is failing. For instance, there is much to suggest that the ‘failure of the system’ to intervene appropriately to protect children rests on something far deeper and more complex than an ambivalence about violence per se towards children. There are other underpinning ambivalences at play, including (and perhaps especially) an extraordinary social–cultural ambivalence about the moral status, moral interests and related moral entitlements of children and the correlative moral responsibilities these entitlements impose on others who come into contact with children (Johnstone 1999b). This ‘moral ambivalence’ has contributed to the ‘failure of the system’, by undermining the confidence of people in taking what Hoff (1982) calls ‘private moral initiative’ and ‘private benevolence’ (read individual moral action) needed to genuinely assist and protect children who are at risk.

If children were genuinely regarded as having moral status and significant moral interests deserving of protection (at least comparable to that otherwise enjoyed by adults), the world’s historical response to child maltreatment and protection may well have been very different. For instance, there may have been less of a tendency both privately and publicly to regard the moral interests of children as being subordinate to the interests of adults (in particular, parents). This, in turn, might have resulted in individuals (including professionals), groups, communities and governments responding more effectively to the problem of child maltreatment and protection than has historically been the case. And it might also have resulted in individuals, groups and communities positioning themselves better to break the cycle of intergenerational violence that has become so characteristic of contemporary societies everywhere. Instead, the problem of child abuse has foundered on a bedrock of moral malaise that, arguably, will not shift until there is a concerted effort at both an individual and collective level to challenge and change the status quo.

Whether driven by legal obligation or moral commitment, or both, a health care professional’s decision to report child abuse (or not report it, as the case may be) never occurs in a moral vacuum and is never free of moral risk. Even in the face of clinical certainty (insofar as this is possible) and the threat of legal and professional censure for non-compliance with mandatory reporting requirements (insofar as this is probable), there is always room to question: Should I report this particular case of known or suspected child abuse and/or neglect? Underpinning this question are the additional questions of: What are the possible consequences to the child of me reporting or not reporting this case? What are the possible consequences to the child’s family/caregivers of me reporting or not reporting this case? and What are the possible consequences to me of reporting or not reporting this case? Possible answers to these questions will depend, in varying degrees, upon an effective harm/benefit analysis of the situation.

Child abuse (often used as ‘an “umbrella” term that covers a wide range of activities that harm children in some way’ [Goddard 1996: 28]), can take a number of forms, including physical, sexual, emotional and spiritual. It can also involve neglect, defined here as ‘the failure to provide the child with the basic necessities of life, such as food, clothing, shelter and supervision, to the extent that the child’s health and development are placed at risk’ (Child Protection Victoria 1993: 3). In some instances, all forms of abuse may overlap; for example, a child who is sexually abused is ipso facto abused physically, emotionally and spiritually as well (Renvoize 1993: 36).

Although historically there has been considerable disagreement about how child abuse can and should be defined (Johnstone 1999b; Goddard 1996; O’Hagan 1993), this is not sufficient to threaten strong moral arguments against child abuse and its intervention, as some have suggested (see, e.g. Lantos 1995: 43). Child abuse can be (and, as shown earlier, has been) defined in ways that unequivocally distinguishes it from other ‘acceptable’ behaviours directed at children (e.g. play, discipline, ‘character building’, education) and it is spurious to suggest otherwise. A key feature of child abuse (not carried by other behaviours directed at children) concerns the risk of non-accidental and culpable harm that it poses to a child’s genuine welfare and wellbeing. These risks are not merely speculative or imaginary, but substantive and known through the supportive findings of rigorous research, an increasing body of professional literature on the subject, and, not least, by the survivors of child abuse themselves who are increasingly coming forward to share their experiences by making their ‘stories’ public.

In all its forms, child abuse can cause significant and lasting harm to children and, ultimately, the adults they become. Borrowing from Archard (1993: 150): ‘A child may be harmed both as a child and as a prospective adult. The adult of the future can be harmed by what is now done to the child.’ It is this consequence of harm that makes child abuse and neglect morally objectionable. Understanding this, however, requires at least a rudimentary understanding of the notion of ‘harm’, the way it is linked to human welfare and wellbeing, and why it is morally compelling both not to cause harm and to prevent harm to others.

As previously considered in Chapter 3 of this text, harm may be taken as involving the invasion, violation, thwarting or ‘setting back’ of a person’s significant welfare interests to the detriment of that person’s wellbeing (Feinberg 1984: 34; Beauchamp & Childress 1994: 193). Wellbeing, in turn, can include interests in:

The test for whether a person’s interests and wellbeing have been violated or thwarted rests on ‘whether that interest is in a worse condition than it would otherwise have been in had the invasion not occurred at all’ (Feinberg 1984: 34). For instance, if a person (e.g. a child, a young person or an adult survivor of child abuse) is left psychogenically distressed (e.g. emotionally unstable, anxious, depressed and/or suicidal) as a result of his/her abusive childhood experiences, our reflective commonsense tells us that this person’s interests have been violated and the person him/herself ‘harmed’. As the American philosopher Joel Feinberg (1984) explains, the violation of a person’s welfare interests renders that person ‘very seriously harmed indeed’ since ‘their ultimate aspirations are defeated too’.

Reporting child abuse, unless consented to by both the abuser and the child (given the child is capable of giving consent), almost always involves a breach of confidentiality and privacy. A key reason health care professionals are reluctant to breach confidentiality concerns a fear that, if abusers cannot rely on or trust professional caregivers to keep secret abuse-related information disclosed in the professional–client relationship, then they (the abusers) may be discouraged from seeking help to remedy their abusive behaviours. In effect, legitimised reporting laws could ‘drive people underground’ (Goddard 1996: 98; MacNair 1992: 129). It is not clear, however, that this fear is sufficient to justify maintaining confidentiality in favour of an abusing adult. There are a number of reasons for this. The first of these concerns the very nature of the moral demand to maintain confidentiality itself.

Traditionally, as discussed in Chapter 6 of this book, the rule of confidentiality has demanded that information gained in the professional–client relationship ought to be kept secret even when its disclosure might serve a greater public good. Over time, however, real-life examples and moral theorising have repeatedly shown that treating the rule of confidentiality as being absolute is morally unjust, indefensible and unreasonable (Bok 1983, 1978). At best, maintaining confidentiality should be treated as only a prima-facie obligation. What this means is that while, as a general rule, confidentiality ought to be maintained in the professional–client relationship, there may sometimes be stronger moral reasons for overriding this obligation. An example here would be where an abusing adult discloses to an attending health care professional his or her intention to deliberately injure a child. A decision to disclose this information in order to warn and protect the intended child victim would be justified on grounds that it could help to prevent an otherwise avoidable harm from occurring.

Superficially, the disclosure of privileged information in the above example might appear to be in breach of a disclosing client’s ‘rights’ to confidentiality. However, confidentiality was never meant to stretch so far as to compel an attending health care professional to lie or to protect those who have no right to impose their malevolence on innocent victims — in this instance an innocent child (Bok 1978: 148). Borrowing from Bok (1978: 155), ‘only an overwhelming blindness to the suffering of those beyond one’s immediate sphere’ could justify the maintenance of absolute confidentiality in the case where innocent others are at risk of being harmed. Further, a client’s moral entitlements to have certain information about themselves kept secret are forfeited where the maintenance of confidentiality about their case stands to seriously impinge on the moral interests and wellbeing of innocent others. In this instance, morally constrained discretionary breaches of confidentiality are morally justified.

In the case of child abuse, there exists strong moral grounds (in addition to mandated legal requirements) for justifiably overriding an obligation of confidentiality that might otherwise be due to an abusing adult, and for discretionary disclosures to be made to appropriate people. In regard to the ‘possible harm’ that discretionary disclosures may cause to abusers (e.g. driving abusers ‘underground’ and discouraging them from seeking help; causing them to feel hurt, embarrassed and stigmatised; dismembering families; and so forth), this is not sufficient to justify the maintenance of absolute confidentiality. One reason for this is: it is not clear that discretionary disclosures will necessarily harm the welfare interests of abusers. The aim of protective interventions (of which the legitimated reporting of child abuse is a form) is to ‘protect children, not to punish abusers’ and to be ‘curative and remedial rather than punitive’ (Corby 2000; Fogarty 1993; Lewin 1994; Miller & Weinstock 1987; Scott & O’Neil 1996). Thus disclosures that are made to appropriate people stand to not only benefit an abused child, but also set in motion a process that could potentially assist the abuser as well. If the abuser is genuinely accepting of responsibility for his or her abusive behaviour towards children and is committed to rehabilitation, then the problem of competing demands to maintain confidentiality can be overcome by the health care provider negotiating the discretionary disclosure of privileged information gained in the professional–client relationship. If, however, an abuser is unwilling to accept responsibility for his or her abusive behaviour and is unwilling to give permission for a discretionary breach of confidentiality to the relevant authorities, the health care professional has an overriding moral obligation (and in some jurisdictions, is legally mandated) to take the action necessary to protect the interests of an at-risk child or children. Discretionary breaches of confidentiality are morally justified in these instances.

In her classic work Trauma and recovery: the aftermath of violence — from domestic abuse to political terror, the American psychiatrist Judith Herman persuasively argues that (1992: 9):

Applied in the context of child abuse, there is room to suggest that without a strong political movement for children’s rights, the process of bearing witness (to child mistreatment) will likewise give way to a communal forgetting. The risk of forgetting is particularly great in an environment which is not supportive of nor encourages personal moral initiative and individual acts of benevolence (moral action) aimed at genuinely assisting and protecting children who are at risk.

Herman (1992: 8) contends that ‘without a supportive environment, the bystander usually succumbs to the temptation to look the other way’. Currently, the social and cultural environment in Australia (as well as overseas) is not generally supportive of child abuse prevention and, to some extent, even supports the position of the ‘morally passive bystander’. For many health care professionals located in this unsupportive environment, looking the other way may seem a preferable option to ‘becoming involved’ (Goddard 1996). This ‘not becoming involved’ might even be seen, controversially, as being a morally preferable option on grounds that it could help to avoid the otherwise unpredictable harmful consequences that can (and do sometimes) flow from intervening or becoming involved in a given child abuse/neglect case. What might not be appreciated, however, is that succumbing to the temptation to look the other way and to avoid involvement is not a morally neutral response. Just because health professionals may have done nothing actively to abuse a child (i.e. they may have merely witnessed evidence of possible abuse), this does not mean that they have avoided complicity in the harms to the child caused by his or her initial mistreatment. Borrowing from Joseph Fletcher (1973: 675) writing in another context, ‘Not doing anything is doing something; it is a decision to act every bit as much as deciding for any other deed.’ Thus, a decision to do nothing to intervene in the prevention of child abuse is every bit a decision nevertheless, and still stands as a link in the causal chain of events between an actual instance of abuse and the harm to the child that can and does follow from this abuse.

In their classic report on protective services for children in Victoria, Fogarty and Sargeant conclude that (1989: 52):

There are not, of course, any ‘quick fix’ solutions to the problem of child abuse and protection. But there is considerable scope to suggest that a lot more could be done at an individual, familial, group, community and state level to improve the status quo. Health care professionals have a particularly important role to play on account of them being in a prime position to discern and provide evidence of instances of child abuse and neglect, and to legitimately intervene to prevent these instances from continuing. Through their informed and morally judicious interventions, health care professionals could, in turn, make a significant difference to the lives and welfare interests of both abused children and abusing adults. Legitimated reporting requirements should, therefore, not be seen as an intrusion or a violation of the professional–client relationship, but as an opportunity to provide support and care to injured and distressed human beings (both children and adults alike).

A system of child protection is only as good as the people who are charged with — and who are willing to accept — the responsibilities of upholding it. All health care professionals have an obligation to become sufficiently informed about the clinical, legal, cultural and ethical dimensions of child abuse to enable them to competently participate in child protection and development processes. And there is small doubt that improving the education of health care professionals about child abuse and protection issues will prepare them to deal better with known or suspected child abuse cases. But, as Judith Herman (cited above) makes plain, commitment and education may not be enough; there also needs to be a supportive social environment and a deeply ingrained cultural commitment to preventing the harms of child abuse and neglect across the board.

It is readily acknowledged that ‘child maltreatment is not a simple problem with easy solutions’ (WHO & ISPCAN 2006: 65). Nonetheless, there are a number of strategies that can be implemented at a societal/community, relationship and individual level that would be conducive to the development of a supportive social–cultural environment that is protective of the needs and welfare of children. Notable among the various strategies recommended by global authorities are:

There has already been a significant move towards adopting a human rights approach to child protection and the prevention of child abuse. In 2006, for example, the UN released the findings of its first ever comprehensive global study on all forms of violence against children. The study is also reputed to be the first UN study ‘to engage directly and consistently with children, underlining and reflecting children’s status as rights holders, and their right to express views on all matters that affect them and have their views given due weight’ (Pinheiro 2006: 3). The release of the UN report is being credited with marking ‘a definitive global turning point’ in terms of the battle to end the justification of violence against children. Through the dedicated work of various international bodies like the WHO, the UN and ISPCAN, there is now a much greater recognition internationally that:

Related to the latter point, there is also a much greater appreciation of why the link needs to be made between child maltreatment and human rights, notably that ‘a human rights approach can reinforce and build commitment towards the type of multidisciplinary public health actions that is necessary to prevent violence [against children]’ (WHO 2001b: 7).

In light of these trends, it is perhaps no coincidence that the UN (1989) Convention on the Rights of the Child (CRC) is, to date, the most widely ratified international human rights treaty and which has ‘set obligations for child protection, prevention of violence, as well as the right to health’ (WHO 2001b: 7).

This chapter has attempted to show that the issue of child maltreatment not only raises a number of important ethical issues, but is itself an important ethical issue. It has also attempted to show that health care professionals have a moral obligation to intervene in the prevention of child abuse and neglect and that this obligation rests on considerations of the welfare interests and wellbeing of children. And while it is acknowledged that the act of reporting child abuse and neglect is one which is fraught with difficulties, the risks of not reporting are equally if not more onerous — not just to abused children but to the community as a whole. In the ultimate analysis, and in support of Fogarty and Sargeant (1989) cited above, ‘each section of the community [including and perhaps especially health care professionals] can and should make a contribution’.

Children should not have to bear ‘silent and unacknowledged witness to their own suffering in many ways throughout their lives’ (Valent 1993: 4). Everyone has a moral responsibility (irrespective of legal law) to break the culture of silence that surrounds child abuse and which has been so effective in invalidating, marginalising and rendering as invisible its untoward effects. Unless this responsibility is accepted and acted upon at an individual and private level, children will remain at risk of the otherwise avoidable harms caused by child abuse and neglect. To fail in this responsibility is not only to fail the most vulnerable members of our society (children), but to fail ourselves and the community as a whole in which we share membership.

Child abuse does not only affect children, it affects us all. It is, therefore, up to each and every one of us (as co-participating members of a moral community) to do what we can in order to prevent it and the harms that flow insidiously from it. Preventing the harms of child abuse is not merely a charitable cause which people can choose to either support or not support. Rather it is an obligation supported by the deepest of ethical considerations and which is binding on all of us. The ultimate question, then, is not one of whether we ought to intervene in the prevention of child abuse, but how we may better intervene and achieve the desired moral outcomes of this intervention.