3 Questions in One Day: #3: Teachers and DNAR

I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.

Question #3: In the event of a cardio-pulmonary arrest should school teachers be required to follow "Do Not Attempt Resusitation" orders written by the parents of incurable, life-limiting, potentially terminally ill children who are still able to attend school? (Reference: American Journal of Bioethics, Jan-Feb 2005)

3 Ethical Questions in One Day: #2: Selling Info about Doctors

I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.

Question #2: Should information identifying physicans be sold by the American Medical Association to pharmaceutical companies so that the physician's prescribing habits can be collected and used for marketing purposes by the pharmaceutical company representatives visiting doctors in their offices? (Reference: San Francisco Chronicle, July 25, 2007 via SFGATE.com)

3 Ethical Questions:in One Day: #1 Right to Meds

I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.

Question #1: Should terminally ill cancer victims who have failed to respond to all standard treatments for their condition have the right to be prescribed and administered drugs which are still undergoing pharmaceutical investigation and are not approved by the FDA for use? (Reference: New England Journal of Medicine, July 26, 2007, p. 408.)

"I Hate Hospitals"

I am sure that most of us hate to be hospitalized. Sometimes, we are compelled by our medical situation to stay in a hospital. Though we may be aware of the benefit of observation and treatment there, nevertheless behaviors of hospitals and their staffs often leave much to be desired. I am sure many of my visitors will have stories to tell (no names please). Though some complaints will be due to misunderstandings (and even misunderstandings represents a problem of communication), many will be clearly issues that are absent from hospital policy, are ignored and remedial action not enforced or are frankly not beneficent to the patient or their family. Thanks to the hospital-oriented publication Blue H News, I got the reference for the following sampling of former hospital patients regarding their consideration of violations of patient rights. I could not find any description of the sampling methodology to present here, but in any event I think it is worth looking over the issues that hospital patients find upsetting for them. Can any of my visitors add to the list? ..Maurice.



In an recent survey of former patients, the National Institute for Patient Rights (NIPR)identified the following as the top ten violations of patient rights:

1. The right to informed consent in accepting or refusing treatment.
2. A respect for personal, spiritual, cultural, and religious values and beliefs.
3. The right to an advance directive, such as a living will or durable power of attorney for health care.
4. The right to privacy and confidentiality.
5. The right to be told of realistic care alternatives when hospital care is no longer appropriate.
6. The right to review the hospital bill, have the information explained, and get a copy of the bill.
7. The right to know about hospital rules on charges and payment methods.
8. The right to know about hospital resources, such as patient complaints and grievance processes, patient representatives or ethics committees.
9. The right to know the identity and professional status of those who care for the patient.
10. The right to review your medical records and to receive an accounting of disclosures regarding health information.
(based on a random sampling of over 1000 former patients)

Discussion of the results of the sampling by the NIPR CEO, Mark Meaney, can be found at Associated Content.

Your Job as Experienced Patient is to Teach Medical Students Ethics and Ethical Behavior

Pretend that you have been given the responsibility to prepare and teach an ethics course for medical students. Your duty would be to provide the students who are learning how to become doctors with the key ethical issues that they may face as they go out into practice. You must also provide them with the knowledge and tools which they need to make fair ethical decisions and be, themselves, ethical. The goal is for all the medical students under your wing to end up as moral, ethical physicians who are free from misbehavior and who are looked upon with trust by their patients and by their medical colleagues. We are all calling for doctors who are good, do good and are honest and trustworthy to care for us and our families. Now, here is your chance, based on your own experiences, to set down in writing what you are going to instruct them and how they will be able to develop the behavior benchmarks that you are setting for them.


You might say to me, "It's hopeless. Students are either ethical or they are not when they come to medical school. Education is not going to help the one's who are not." Really?
You might say to me, “I am not a physician, philosopher or a teacher..I am only a patient!” Don’t give up on this challenge. The approaches suggested by experienced patients to teaching medical students ethics and ethical behavior may be more constructive and realistic then what is coming from our current medical school teachers. Give it a try. Medical school classes for the first and second year students begin in just a month and we have to get an ethics program started now. Even if you respond after classes begin, we can always change course. Remember, setting the students on the right path is more constructive than later just complaining about them as physicians and mumbling “I hate doctors”. ..Maurice.

Pay for Performance: Doctors, Hospitals and Pills

So you want a change in the way medicine is practiced? You are not satisfied with the way doctors and hospitals perform their duties? Do you want to find a way to get treatment from “better” doctors; doctors who are able to do a better job to cure you but with less risk of complications? Would you like to see all doctors and hospitals required to follow protocols and achieve benchmarks for the results of treatments based on evidence based medicine studies or statistically achievable norms? Should their report cards be made public regarding how well they are following the rules ad how well they are doing?

Would you like to select from a list of doctors and hospitals who are better than others and know which doctors and hospitals one should avoid? Should doctors and hospitals be paid by patients, insurance companies and the government based on where on the list of acceptable performance they are located?

How about pills and other medicines? Would you like for pharmaceutical companies to be held responsible through selective payment based on results? Would you like to have the ability to pay for them only if they prove to be effective in improving your very own condition and not pay for them or get full refund of your money if you they show no results for you personally?

You may not be aware that all this is not some futuristic dream but is already by little spurts going into practice. It has a name: Pay for Performance. The question is when all medical care is practiced this way will there be a net benefit for the patient and society in general. Are there any problems, flaws or something unethical that you can see in this concept of improving medical care? Let’s hear from you. After all, Pay for Performance is all being done for you. ..Maurice.

Read more about this:

Report cards and benchmarks for doctors and hospitals:”Is Zero the Ideal Death Rate?” by Thomas H Lee, M.D.,David F. Torchiana, M.D., and James E. Lock, M.D., New England Journal of Medicine, July 12, 2007 issue page 111.

AMA: Delegates Want Principles First with Pay for Performance (MedPage Today)

Pricing Pills by the Resuts (New York Times)

Doctor of a Nation or Doctor of a Political Party: Duty of the U.S. Surgeon General

From today's Los Angeles Times:

President Bush's first surgeon general charged today that administration officials prevented him from providing the public with accurate scientific and medical information on such issues as stem cell research and teen pregnancy.

"The reality is that the 'nation's doctor' has been marginalized and relegated to a position with no independent budget and with supervisors who are political appointees with partisan agendas," Dr. Richard H. Carmona told the House Committee on Oversight and Government Reform. "Anything that doesn't fit into the political appointees' ideological, theological or political agenda is ignored, marginalized or simply buried.

"The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science or marginalizing the voice of science for reasons driven by changing political winds," said Carmona, who served from 2002 to 2006. "The job of surgeon general is to be the doctor of the nation — not the doctor of a political party."

So, who is the Surgeon General and what is his or her duties? Here is some background information from Wikipedia:

The Surgeon General of the United States is the head of the United States Public Health Service Commissioned Corps and, ex officio, is the leading spokesperson on matters of public health in the U.S. government. The Surgeon General is nominated by the U.S. President and confirmed via majority vote by the Senate. The Surgeon General serves a four year term of office and is commissioned as a Vice Admiral in the PHSCC. [1] In carrying out all responsibilities, the Surgeon General reports to the Assistant Secretary for Health, who is the principal advisor to the Secretary of Health and Human Services on public health and scientific issues, and who serves as the overall head of the United States Public Health Service. The former Surgeon General, Vice Admiral Richard Carmona, appointed by President George W. Bush in 2002, left office when his term expired on July 31, 2006. [2]. Rear Admiral Kenneth P. Moritsugu is functioning as the Acting Surgeon General. [3].

On May 24, 2007, President Bush nominated Dr. James W. Holsinger, Jr., a University of Kentucky medical professor to be the 18th surgeon general of the United States. [4]

The Surgeon General functions under the direction of the Assistant Secretary for Health and operationally heads the 6,000-member Commissioned Corps of the United States Public Health Service, a cadre of health professionals who are on call 24 hours a day, and can be dispatched by the Secretary of HHS or the Assistant Secretary for Health in the event of a public health emergency. The Surgeon General is also the ultimate award authority for several public health awards and decorations, the highest of which that can be directly awarded is the Surgeon General's Medal (the highest award bestowed by board action is the Distinguished Service Medal).

The Surgeon General also has many informal duties, such as educating the American public about health issues and advocating healthy lifestyle choices.

The office also periodically issues health warnings. Perhaps the best known example of this is the Surgeon General's Warning labels that can be found on all packages of American cigarettes. A health warning also appears on alcoholic beverages.

Past American Surgeons General have often been characterized by their outspoken personalities and often controversial proposals on how to reform the U.S. health system. Because the office is not a particularly powerful one, and has little direct impact on policy-making, Surgeons General are often vocal advocates of unconventional, unusual, or even unpopular health policies. Vice Admiral C. Everett Koop and Vice Admiral Joycelyn Elders were two former Surgeons General who were well known for their controversial ideas, especially on sex education.

The U.S. Public Health Service was under the direction of the Office of the Surgeon General and was an independent government agency until 1953 at which point it was integrated into the United States Department of Health, Education and Welfare, and later into the United States Department of Health and Human Services. Although the U.S. Public Health Service and the Surgeon General were at various times under the umbrella of the Department of the Treasury or the Federal Security Agency, the agency operated with a substantial amount of independence.

The U.S. Army, Navy, and Air Force also have officers overseeing medical matters in their respective services who hold the title Surgeon General.

In Republic of Ireland and United Kingdom, the term chief medical officer is used as equivalent.


Service rank
The Surgeon General holds the rank of Vice Admiral [5] in the Public Health Service Commissioned Corps, one of the seven Uniformed services of the United States. Officers of the PHSCC and the National Oceanic and Atmospheric Administration Commissioned Corps are classified as non-combatants, but can fall under the uniform code of military justice (UCMJ) and the Geneva Convention when designated by the Commander in Chief as a military force. Officers Members of these services wear uniforms that are similar to those worn by the U.S. Navy, except that the commissioning devices, buttons, and insignia are unique. Officers in PHS and NOAA wear unique devices which are similar to U.S. Navy Staffing Corps Officers (e.g., Medical Services Corps, Supply Corps, etc.)

Though in today's Congressional hearings where Dr. Carmona and two previous Surgeon General's told their story of political pressures being applied to the Surgeon General during the current and previous administrations, it was brought out that Carmona in the current administration was under the most pressure. It is interesting to find that President Bush who has made much of the fact that he was depending and listening to the views of the "generals on the ground" would seem to avoid listening to his Surgeon General about the science regarding stem cell research and teen pregnancy and stick to his political ideology. ..Maurice.

More on the Mentally Ill:King Lear and the Madness

fear I am not in my perfect mind.
Methinks I should know you and know this man;
Yet, I am doubtful; for I am mainly ignorant
What place this is; and all the skill I have
Remembers not these garments; nor I know not
Where I did lodge last night. Do not laugh at me.
(William Shakespeare (1605) King Lear, Act IV, Scene 7)

As an extension to my recent threads on how informed consent should be obtained in pharmaceutical experiments on the mentally ill and whether the mentally ill should be given assisted suicide, I wanted to include a posting about a classic example of mental illness in literature, Shakespeare's King Lear, and how mental illness was explained long ago and how it was treated. Did King Lear have Alzheimer's Disease or some other psychiatric illness? Whichever, it was a therapeutic challenge then and today in many ways it is still a challenge.

The following is an essay on King Lear, his madness and how mental illness was evaluated in the Renaissance period. I obtained it from John Mark Ministries

(Note: I took the above photograph of the painting of King Lear and Cordelia by Benjamin West today at the Huntington Library and Botanic Gardens, San Marino, CA). ..Maurice.

Renaissance Views of Madness: King Lear
By Adrian Ingham, December 1996

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The essay that follows was researched and written by Adrian Ingham as part of the course on Shakespeare by Individual Studies, 1996; it is reprinted here with his permission. While copyright is retained by Adrian Ingham, this material may freely be used for educational and non-profit purposes, so long as the author and source are cited.

Samuel Johnson describes the age of Shakespeare as a time when "speculation had not yet attempted to analyze the mind" (118), but there was a range of theories and opinions regarding madness. And although it has been demonstrated that Shakespeare's portrayal of madness parallels Bright's A Treatise of Melancholie (Wilson 309-20), that medical model alone is insufficient to describe the madness of King Lear. Shakespeare was not limited to a single book in his understanding of madness; he had at his disposal the sum total of his society's understanding of the issue. Since Lear's madness is derived from a mixture of sources, it can only be effectively described in this larger context.
Because much of Renaissance medical theory was based on premises from the Middle Ages, a starting point for our understanding of Lear's madness can be found in the 1535 translation of De Propriatibus Rerum by the thirteenth century monk Batholomaeus Anglicus. This work is based entirely on the traditional model of illness as an imbalance of the four humours: melancholy (or black bile), choler (or yellow bile), blood, and phlegm. Batholomaeus classifies melancholy and madness separately, attributing them to different humours and different areas of the brain (1-4). The condition of melancholy is caused by an excess of the melancholy humour. It makes a person "ferefull without cause, & oft sorry. And that is through the melancholi humor that constreineth & closeth the herte" (2). In extreme cases melancholy causes symptoms quite like madness, "somme fall into evyll suspections without recover: & therfore they hate - blame, and confounde theyr frendes, and sometyme they smyte and slee them" (2). But although Lear could be described as falling into "evyll suspections" he probably does not have melancholy. He is choleric by nature and it is likely that his madness is caused by an excess of that humour. Goneril describes his choler and foreshadows his madness in an early attempt to discredit him:

The best and soundest of his time hath been but rash; then must we look from his age to recieve, not alone the imperfections of long-engraffed condition, but therewithal the unruly waywardness that infirm and choleric years bring with them. (1.2.294-298)
In Bartholomeus' model madness caused by an excess of choler is called "the frenesie". Its signs are "woodnes and contynual wakynge, mevynge and castynge aboute the eyen, ragynge..." (3). It is caused by the red choler "made lyght with heate of it self... ravysshyd upwarde by veynes, synewes, wosen and pypes" (2). The cure involves bleeding the patient, shaving his head and applying vinegar and ointment to the head. However it also recommends creating a calm environment for the patient, feeding him a sparse simple diet, and "above all things... men shall labour to bringe hym a slepe" (3-4). Kent seems to be aware of this most important part of the cure, and through him we realize that Lear's madness may have been shortlived had he been able to rest before fleeing to Dover:

Oppressed nature sleeps.
This rest might yet have balmed thy broken sinews,
Which, if convenience will not allow,
Stand in hard cure. (3.6.94-98)

However, not all contemporary models of madness relied solely on humours. Timothy Bright's model simplifies Bartholomeus' categorization of madness by calling all madness melancholy, but diversifies it by distinguishing two separate types of melancholy. In Brights words: "the difference is betwixt natural melancholie, and that heavy hande of God upon the afflicted conscience, tormented with remorse of sinne, & fear of his judgement" (37). Natural melancholy resembles Bartholomeus' model in that it has humoreal origins and in its extreme manifestation the melancholy humour can cause "stormes of outrageous love, hatred, hope or feare, wherewith bodies so passionate are here and there, tossed with disquiet..." (Bright 38). But unnatural melancholy has no parallel in the medieval model. Natural melancholy can be recognized from the general symptoms of madness occurring in a stable person in a stress free environment. In this case the madness can only be attributed to physical imbalances (38), while unnatural melancholy, ironically, can be recognized by its occurrence in situations when it seems more natural to go mad: situations in which the mind is tormented by worry and stress (37). The natural/unnatural distinction should not be taken to imply rarity or probability but rather physical or non-physical causes. In Bright's model, like Bartholomeus', Lear would probably not be diagnosed with natural melancholy. We have seen that he is naturally choleric rather than melancholic, and he certainly has recognizable cause to go mad from mental stress and guilt, as Kent, once again, recognizes:

A sovereign shame so elbows him: his own unkindness That stripped her from his benediction, turned her To foreign casualties, gave her dear rights To his dog-hearted daughters -- these things sting His mind so venomously.... (4.3.44-49)

And because Lear is suffering from unnatural melancholy, his prognosis is not good in Bright's model: "Here no medicine, no purgation, no cordiall, no tryacle or balme are able to assure the afflicted soule and trembling heart, now panting under the terrors of God" (39-40). So we see that mere rest may not have been enough to cure Lear's condition. Upon his reconciliation with Cordelia it is rest which calms his anger, but it is her forgiveness which brings him out of his depression. Had Lear not been parted from her again through her death he may well have survived his madness.
Had Lear survived, however, it would not have been to recover his former self. Lear's madness is a journey as much as it is an illness. Even in his brief interlude of lucidity before Cordelia's death he is a different man:

When thou dost ask me blessing, I'll kneel down And ask of thee forgiveness. So we'll live, And pray, and sing, and tell old tales, and laugh At gilded butterflies, and hear poor rogues Talk of court news... (5.3.10-14)

This humble speech to Cordelia is in reaction to the affront of losing a war and being led to prison; compare it to Lear's reaction to friendly advice from the Earl of Kent at the beginning of the play:

Hear me, recreant, On thine allegiance, hear me! That thou hast sought to make us break our vow -- Which we durst never yet -- and with strained pride To come betwixt our sentence and our power -- Which nor our nature nor our place can bear... (1.1.166-71)

Through his madness Lear breaks down the false illusions of his courtly world. Where the earlier speech is concerned with power and title, the later speech is concerned with humanity and friendship. Lear's madness can be seen both as a result of his arrogance and as a remedy for it: "Lear's experience is purgatorial; madness is both punishment and insight" (Byrd 7). The Fool's statement that "truth's a dog must to kennel; he must be whipped out" (1.4.111-12) foreshadows the pain that Lear will have to pass through before attaining enlightenment. This vision of madness is characteristic of Shakespeare's era. The Renaissance held the Aristotelian view that there is a fine line between madness and divine inspiration (Skultans 20), but by the eighteenth century madness was viewed as no more than degradation and shame. In testimony to this, the eighteenth century's favorite version of King Lear was a version rewritten by Nahum Tate to include a happy ending (Byrd 7-8). In this version Lear recovers from his illness, wins the battle and reigns again: by suffering madness Lear pays for his sins and is returned to health and prosperity. In contrast to this, Lear's transformation in the original play leaves him so guileless that it is unlikely that he would survive long with the intrigues of running a kingdom even if he had won the war. When Lear dies it is because he has finally learned to love; and when the one he loves dies, the intensity of his sorrow kills him. "His death is a release from suffering, but also a testimony to what he has become" (Byrd 8).
Thus Lear's madness transcends a purely medical model. Lear is a fusion of not only Bright and his predecessors, but also of Renaissance feelings towards madness. The medical model had not changed significantly by the eighteenth century, but common opinions about madness had. The fact that Tate's maudlin happy ending was ever preferred to Shakespeare's original is testimony to the difference that such attitudes can make. While the similarities between Shakespeare's mad men and Timothy Bright's A Treatise of Melancholie are evident, it would be a mistake to infer from these parallels that the characters are based solely on that model. They are, instead, derived from both medical and non-medical sources, and they can be most effectively analyzed using a simular variety of sources.


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Works cited
Bartholomaeus Anglicus. De Proprietatibus Rerum. Qtd. in Hunter 1-4.
Bright, Timothy. A Treatise of Melancholie. Hunter 36-37.
Byrd, Max. Visits to Bedlam: Madness and Literature in the Eighteenth Century. Columbia: U of South Carolina P, 1974.
Hunter, Richard, and Ida MacAlpine, eds. Three Hundred Years of Psychiatry 1535-1860: a History Presented in Selected English Texts. London: Oxford UP, 1963.
Johnson, Samuel. "Preface." Johnson on Shakespeare. Ed. R. W. Desai. New Delhi: Orient, 1985.
Shakespeare, William. "King Lear." William Shakespeare: the Tragedies, the Poems. Ed. John D. Wilson. Cambridge: Cambridge UP, 1986.
Skultans, Vieda. English Madness: Ideas on Insanity, 1580-1890. London: Routledge, 1979.
Wilson, J. Dover. What Happens in Hamlet. Cambridge: Cambridge UP, 1967.

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Child Abuse and Neglect: Where There's Smoke is There Always Fire?

What exactly is child abuse? On what basis can a provider be charged with that potentially criminal behavior? This issue was brought to my attention today by an e-mail from a concerned parent which I will post here but anonymously. I then would like to present my response to him. Finally, though much has been already written on child abuse from the legal, child protective viewpoint, I thought it might be interesting but also fair to read the views of another side, a representative from the provider vulnerability side.

Finally, as my visitor, what are your views on the subject of provider vulnerability when child abuse or neglect is the issue? Should anyone worry about the providers of the child in question? ..Maurice.

1st off.. me and my girlfriend have a baby (5 months old now)

i had a beer with my dinner one night and my girlfriend decided to drink heavily. later on, my girlfriend got angry at me and we fussed alot... fearing the situation was spiraling out of control, i called the police. when they arrived, they arrested her for child neglect, however, i was sober and they arrested me saying i was drunk too!! I even requested a breathalizer test but was denied (stating its only used in driving casses) DSS came and took our baby!


we have a VERY happy and PERFECTLY healthy baby girl. Not a scratch has/or EVER will be placed on her.

although i had a beer earlier in the evening, and WAS sober and alert,
Is what has happened to me child neglect?

Reply:

I think I can imagine how concerned and upset you are now. I am not a lawyer and I don't know the applicable laws in the area where you live so I can't specifically answer your question. My best advice to you, as you probably are already aware, is to contact a lawyer. As I suggested, the criteria to define "child abuse" is variable both ethically and legally. At one extreme, personally and intentionally physically damaging their child is considered abuse. A mother or father driving a vehicle with their small child in the car but without proper restraints has been called abuse. Going to another extreme, the term has also been used for parents who allow their child to become obese. You can therefore see what I mean when I say "variable".

Even though I haven't answered your question, I do extend my best wishes to you, the mother and your child. ..Maurice.

The following is by Marian Ruth Turner and the Family Child Care Page

Some Myths of Maltreatment Allegations and Caregiver Risk
by Marian Ruth Turner, Coalition on Provider Vulnerability

Marian Turner was a postal letter carrier before opening her family child care business in 1971. She enjoys baking, bookkeeping, research, mythic storytelling, and physical care. After 32 years of ten- hour days, her back aches, and she can't sit at meetings anymore, but she still can't think of a better job than family day care. Marian likes learning, and hates teaching.
(Copywright 1999. This essay may be reproduced, but you must give credit to Marian Ruth Turner and the Family Child Care Page.)



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Have you heard about that provider? the one who broke the baby's arm? the one who let the school-ager get into the matches? the one who's teenage son was fondling the 5-year-old?

The myth: where there's smoke, there's fire; an allegation must have some truth to it. This is a very pervasive and destructive myth about allegations of child maltreatment. The hard truth is that where there is smoke...there is smoke. Period.
The reality: all people in crisis deserve support, unconditionally. An allegation is a story, a rumor. Hearing it, you don't know what to believe. Exactly.
Some people accused of child maltreatment are innocent. Some are guilty. Some are in the middle. You can't tell which is which. Innocent people and guilty people say the same things, and show the same distress.

If a neighbor's house is gutted by fire, and you know for certain they smoke in bed, would you refuse to let them use your telephone?

Whether innocent or guilty, caregivers who go through a maltreatment allegation undergo profound grief, just as if someone had died. The stages of grief sweep through, affecting sleep, appetite and self-esteem. Afterwards, healing is slow, hampered by post-traumatic stress syndrome. This is heavy stuff.

***

My interest in providers' rights began, in part, because society changed very fast during the 70s and 80s, our ideas on child-rearing changed. I heard stories of caregivers who were fired on-the-spot or had a license revoked because of behaviors that would have been fine in 1970, but not in 1985. The flush labor market supported a throw-away attitude toward workers. There was little training and no support available to guide providers in adjusting to the new rules.

The myth: you can protect yourself from allegations of child maltreatment. Excellence will protect you. Honesty will protect you. Good intentions. Reputation. Innocence. Awards.
The reality: the honest answer is no, but you can be sensible, and take precautions. It is like 'burn-out' in this regard. It happens, and you deal with it. You can communicate with your clients. You can document, as a habit. You can learn to keep a closed mouth if you tend toward nervous chatter.
Maltreatment allegations are a risk for all caregivers, in nursing homes, foster homes, day care centers, and family child care homes, regardless of their commitment, training, or skill.

Some risk of maltreatment allegation is in the very nature of the work, being immersed with a vulnerable population. Our culture is ambivalent about adult-child relationships.

***

My interest in providers' rights began, in part, because of the male provider who is my business partner. At the annual 'Men In Child Care' retreat he learned new finger plays. He also heard discussions year after year on how to guard yourself from exaggerated fears of sexual misconduct with children. Minnesota is a leader in encouraging men to enter the field, but most of them don't stay long.


The myth: it is better to err on the side of the children. To protect children we must believe them, which means not believing adults.

The reality: to err is to err. Treating a confused child as abused is not in fact helping her to shed confusion, or 'protecting' him from anything; it is like a medical mis-diagnosis.
It is possible, and important, to improve the current system of maltreatment investigation. Children and adults both need to know they will not be sacrificed by mistake.

In the ideal, providers would say that no matter how unpleasant it was to go through that investigation, they were impressed with the process, and the staff's professional behavior.

We cannot in the long run protect one group by sacrificing another group.

***

My interest in providers' rights crystalized when I observed an especially incompetent investigation. With my general knowledge of family child care I could see and interpret things that were obvious to me, but were grievously invisible to the investigator. This provider lost thousands in legal fees, and suffered irreparable damage to her reputation.


The myth: let the professionals do their job. While an investigation is in progress, either licensing or child protection, the provider's role is to wait.

The reality: you are the lead professional in every situation every day. You cannot control the situation, but there is one thing you can control.
Your demeanor can be civilized. Your courtesy (or lack) will be the one thing everyone notices and remembers. Superficial? No. You have duties.

Be persistent, business-like, knowledgeable. You have rights.

Document your own investigation. Log, tape record, keep notes. This can take months or years.

Remember, people who are accused of child maltreatment should never be labeled as child abusers by co-workers, neighbors, or rivals. It is unattractive, unkind, and unprofessional, and it might be untrue.

***

When the Coalition on Provider Vulnerability began meeting, 50 people came, mostly by word of mouth. They were from centers, family child care homes, foster care, and group homes. Subsequent meetings included volunteer attorneys, a retired judge, social workers, an anonymous licensing worker, all troubled by an imperfect regulatory system that harms people. This is not a fringe issue.

The myth: stiffer licensing standards will increase quality in child care.
The reality: rules alone do not create overall quality, but debate can.
Rules can encourage and support quality by standardizing the behaviors in the field. This eliminates both the very worst and the most brilliantly best, leaving a great average middle. While not totally exterminating the colorful eccentricity that used to exist, licensing does make child care programs more predictable.

Quality always comes from within. Quality is intentionality. Standardization is not quality, but it does allow the public and the regulators to see and count and judge certain program qualities.

***

I heard the whining, furious, shamed voices of people caught in an unexpected legal and financial nightmare. Some of them are literally told they have no rights, told they are not allowed to speak to anyone, threatened with having their own children taken for 'neglect' if they fight the allegations.


The myth: children don't lie about abuse. This well-meant generalization is confusing.

The reality: they do sometimes, and they also tell untrue things without lying.
Adults and children have memory confusion. Saying that children invent memories is not an insult to children. Adult witnesses of crime scenes are notorious for contradictory accounts. Research on memory is incredibly interesting.

Children say untrue things at a high rate, and they also stun us with accurate, insightful truths.

Of course, children's confidences should be listened to. Their stories should not be dismissed as outrageous fabrications, even if sometimes they are. A good comparison is the citizen who jokes at the airport about smuggling a bomb in his suitcase. Suddenly he is the center of attention. He can say it is just a joke, but he and the suitcase will be scrutinized, just in case.

Interviewing children is a specialty, eliciting information without contaminating possible evidence. Recording the interview is critical.

***

My passion for the issue of providers' rights pushed me to overcome my shy reluctance for public speaking. The aura of a basic civil rights struggle is not just illusion, and it gave me courage. When people patronizingly explained that providers had to sacrifice their rights in order to ensure the well-being of children, I just knew it was Wrong. If I couldn't make the field safer, it would be time to get out. In other organizations I took minutes or chaired the bylaws committee. In the Coalition on Provider Vulnerability, I became Convenor of the meetings.


The myth: bad things happen more often in day care homes (or in centers). Nonsense.

The reality: insurance statistics show off Minnesota's excellent licensed homes.
Comparing child care homes with centers is like comparing soccer and basketball. They both have a team, they both have a ball, but... one group is always using hands on the ball, the other group is using their feet.

Informal community standards tell the story. For example: mixed-age groups are better than separated ages. Play is better than instruction. Pot luck suppers are better than meetings.

Don't agree? Fine; many providers don't.

***

Themes emerged among the sad stories, and the Coalition focused on practical action. We took several years to brainstorm on all the perceived weaknesses in the regulatory and protection systems, taking in many viewpoints on what to 'fix'.

Agencies always have some great staff and some rotten staff. We wanted to strengthen the built-in structures so the rotten staff would be held accountable, just like we are, and the great staff would not be punished by adding a great burden of unworkable rules.

The myth: there are a few 'bad' providers who should be driven out of child care.

The reality: our single greatest strength is diversity among providers, not just color and religion, but the deep differences in character that define values such as risk and privacy and tidiness. Parental preference is diverse, too.
What looks different isn't bad.



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For further reading:
Robin, M. (Ed), multiple authors (1991). Assessing Child Maltreatment Reports: The Problem of False Allegations. Child & Youth Services, 15 (2), entire issue. Haworth Press.



Phipps-Yonas, S., Yonas, A., Turner, M., & Kauper, M. (1993). 'Sexuality in Early Childhood: The Observations and Opinions of Family Daycare Providers'. CURA Reporter, 23 (2), 1-5. University of Minnesota.



Kulp, J. (1993). Families at Risk: a guide to understanding and protecting children and child care providers involved in out-of-home or adoptive care, Minneapolis, MN: Better Endings New Beginnings.



Jordan, N.(1993). Sexual Abuse Prevention Programs in Early Childhood Education: A Caveat. Young Children, 48 (6) 76-79.



Hammerslough, J. (1998). Could You Be Accused of Child Neglect? Parenting, June/July 1998, 122-129.



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| Essays on Child Care | My Life as a Child Care Provider | Coalition on Provider Vulnerability |
| Child Care Horror Stories | Index Family Child Care Page |
| Send E-Mail to Marian |
Rev. March 3, 2004

ADDENDUM 7-5-2007: Photograph taken by me today in the sculptural garden of the Huntington Library and Botanic Gardens, San Marino, CA.