Moral and Ethical Framework Appraisal

high-risk area of paediatrics with paediatricians increas- ingly reluctant to be involved,7 especially as expert wit- nesses or in controversial areas (e.g. suspected fabricated or induced illness). There are fears that this will have harmful consequences for the protection of future children.

Emotional responses are understandable given the nature of child protection, and such responses and intu- itions may be morally important. Moreover, the ability to have feelings towards others and to respond to them is an essential part of any interpersonal relationships – and pro- fessional relationships are no exception. But such responses highlight rather than preclude the need for rational analysis. This paper analyses some of the issues raised by child protection and suggests responses to them.

The general duty of care and standard of care

Clinicians should have the best interests of their patients as their first concern. This involves two sometimes con- flicting obligations, namely:8

● to provide treatment that confers more benefits than harms;

● to respect patients’ rights to exercise as much self- determination (autonomy) as they are able.

P A P E R S

Ethical issues in child protection

Vic Larcher

Great Ormond Street Hospital, London, UK

Email: [email protected]

Abstract

The management of child protection concerns arouses strong emotions and controversies and creates

ethical tensions for all concerned. This paper provides a rational analysis of some of the issues involved

and suggests responses to them.

The ethical and legal duties of health-care professionals are to act in the best interests of the child

by safeguarding children and reporting concerns. But this may involve conflicts with parents and

produce reluctance of professionals to become involved, especially in controversial types of abuse.

Mandatory reporting of concerns might overcome such reluctance, but may be ineffective in the face

of diagnostic uncertainties. Assembly of a stronger diagnostic evidence base would seem ethically

justified, but organization of the necessary case controlled studies might be problematic. Even with a

comprehensive evidence base, individual diagnoses of abuse will always involve value judgements that

should be underpinned by effective training and assessment of core competencies of professionals.

These manoeuvres are unlikely to prevent both justified and vexatious complaints, often in relation to

breaches in professional duties or concerning professional misconduct. The tendency to blame experts

may have contributed to a reluctance of other professionals to become involved, despite proposals for

reforms in the expert witness and court systems.

Current approaches to child protection may neither promote greater understanding nor be in the

best interests of children. A revised social contract for the effective protection of children could include:

a duty of care that adequately addresses the primacy of the child’s welfare; the acquisition of a sound

evidence base; professional transparency and accountability (but with protection from malicious and

vexatious complaints); and a shift emphasis towards a more inquisitorial system that embraced the

principles of truth and reconciliation.

Clinical Ethics 2007; 2: 208–212

Introduction and background

The investigation and management of actual or suspected child abuse, maltreatment or neglect continue to generate intense emotions and controversy.1 Although it is clear that some children are abused or neglected, the evidence upon which suspicions or diagnoses are based is increas- ingly questioned.2,3 There have been recommendations that the investigation and management of child protection (CP) concerns be addressed with greater professional transparency, responsibility and accountability.4 Pro- fessionals attract censure for both perceived failures and over-zealousness in protecting children.5 They increasingly face complaints6 and accusations of professional miscon- duct and negligence, especially in their role as expert wit- nesses. In consequence, child protection has become a

Vic Larcher did his basic medical training at Cambridge University and St Bartholomew’s Hospital. He then trained as a paediatrician with specialist interest in children’s liver disease with the late Alex Mowat at KCH London. He was appointed consultant paediatrician at Queen Elizabeth Hospital for Children (subsequently Royal London) and as consultant in Paediatrics and Clinical Ethics at Great Ormond Street (2005). He did his MA in Medical Ethics and Law at King’s College London. He is chair of Great Ormond Street and ICH REC and co-chair of GOSH Clinical Ethics Committee, RCPCH Ethics Advisory Committee.

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Ethical issues in child protection 209

The standards required to fulfil these duties are set out in codes of good medical practice,9,10 defined in law11 and emphasized in a code of professionalism.12 They apply just as much to CP as they do to any other area of medical practice.

Young children lack the necessary criteria of under- standing, rationality, self-awareness and reflective capacity that would enable their autonomy to be respected. However, age alone is not the sole determinant of a child’s capacity to make informed choices about whether to undergo treatment or investigation. For a child who lacks capacity, those with parental responsibility have the ethi- cal duty and legal power to make decisions provided that they act in his or her best interests.

Actual or suspected abuse or neglect and best interests

The child health professional’s primary ethical and legal duties are to the child.13 In normal circumstances profes- sionals and parents work together in the best interests of the child, in a relationship based on trust and mutual respect.

In actual or suspected abuse professionals may have good reason to believe that the actions or behaviour of parents/carers are not in the best interests of the child. They may find parental accounts of the child’s injury or illness implausible or inconsistent. Unlike lawyers, who must accept that their clients are telling the truth, doctors have no such obligation if there are good reasons to sus- pect otherwise, thus undermining the basis of the thera- peutic relationship. Difficulties may also arise if a parent believes that the doctor is not taking his/her account of the child’s illness seriously. This is especially problematic when the doctor suspects that the child’s symptoms are being exaggerated, fabricated or induced.1,14,15

All medical interventions, including those which form part of CP investigations, require valid, adequately informed consent.11,16 Parents have the power and respon- sibility to give consent on behalf of young children who cannot do so for themselves. However, they may be reluc- tant to consent to interventions that are intended to cor- roborate abuse (e.g. detailed skeletal survey X rays, forensic examinations in sexual abuse cases) and may, as a consequence, lead to the removal of their child. For many ‘incompetent’ children in whom abuse is suspected such interventions are in the child’s best interests because they are intended or necessary to protect the child from harm. Yet professional discomforts in performing sometimes inva- sive investigations without wholehearted parental agree- ment remain.

Matters are more complex for legally competent older children who refuse to undergo examination in cases of suspected or actual child sexual abuse. There are strong ethical justifications for respecting their refusal, irrespec- tive of its consequences; it could be regarded as unethical to force examination on any child who was capable of informed refusal, even if it were regarded in her best inter- ests to proceed.

The duty of care in child abuse

The duty of all professionals confronted with actual or sus- pected abuse or neglect is clear. They should act in the

best interests of children by protecting them from avoid- able harms that may lead to serious physical or emotional injury. All involved in the care of children should respond to CP concerns in an appropriate fashion and with as much care and intellectual rigour as they might show in dealing with a serious physical condition.4 Mandatory reporting of abuse has been suggested as a means of ensur- ing that professionals fulfil this duty. However, diagnostic uncertainties, lack of evidence base for all types of abuse, lack of core competencies to deal with particular types of abuse, and fear of censure or complaint may all lead to reluctance to be involved and lead to recruitment difficul- ties to posts that carry specific CP duties.17

Mandatory reporting of concerns

Some countries have introduced mandatory reporting of CP concerns.18,19 However, definitional and diagnostic problems produce ambiguities and difficulties in setting reporting thresholds that are neither too specific nor too generous.20 Mandatory reporting may lead some profes- sionals to become over-zealous in reporting so as to avoid risk of censure, while others might prefer risking sanctions from non-reporting to the social and professional conse- quences of accusations of wrongful reporting. More worry- ingly, others may respond by not identifying features of abuse – by limiting clinical assessment to the bare mini- mum – or by avoiding child protection duties altogether.21

There is little evidence that mandatory reporting improves reporting rates or increases the numbers involved in child protection work. Moreover, it might have other unfore- seen adverse consequences for the welfare of children and families, e.g. by compromising therapeutic relationships.22

In the UK it could be argued that the 2004 Children Act23

and designation of the child protection register as a database create a legislative basis for mandatory reporting, but this has not lessened reluctance of professionals to be involved in CP cases. Mandatory reporting is also unlikely to be effective when there is diagnostic uncertainty or when there is insufficient evidence to confirm or refute suspicions.

Responding to diagnostic uncertainty

Responding to diagnostic uncertainty creates dilemmas for professionals. One response is to perform further investiga- tions intended to: (a) exclude natural conditions that might help to explain the child’s symptoms; or (b) provide protection from possible accusations of negligence or mis- conduct.

Some investigations may benefit the child by enabling positive diagnoses of abuse to be made (e.g. identification of perpetrator DNA in sexual assault) or enabling relevant treatments to be given (e.g. treatment of sexually trans- mitted diseases). Others have less tangible benefits but may prevent injustice to individuals on whom suspicion is misplaced.

However, a balance needs to be struck between per- forming investigations that safeguard the interests of carers and the need to protect children. For example, the attempt at exclusion of brittle bone disease in a child with multiple fractures, by searching for specific defects in col- lagen synthesis, or the genes that might lead to them, may be fair to parents or others suspected of abuse of the child.

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taking them might be via the PIAG system.28 Collection of anonymised normal data from existing health-care records might not require specific consent, but would require ethical review. Any approach requiring contact with children or families would require scientific and ethi- cal review and consent. Public consultation and involve- ment in the design of research projects should provide greater transparency and understanding and possibly aid recruitment in these sensitive areas

However, it is important to recognize the limitations of this approach. Even sophisticated evidence bases are unlikely to define the precise force necessary to produce a particular injury in a particular individual. This will always involve balancing probabilities using professional judge- ment in accordance with professional values and stan- dards, for which training is necessary.

Maintaining standards to fulfil duty of care

Professionals should approach the investigation of CP con- cerns with the same standards that apply to other aspects of medical practice. This requires adequate training designed to maintain defined levels of competency and reduce apprehension and in turn provide some protection against complaints.29,30 Although an evidence-based, com- petency defined, accredited training programme in child protection for entry-level junior doctors has been estab- lished, a similar programme for higher trainees and consul- tants is also needed, with the means to test its effectiveness.

Until uniform training and accreditation systems are established, requirements for regular updating in child pro- tection skills for could be built into the appraisal system in a similar fashion to the need to update life support skills.30

To avoid censure and complaint, paediatricians will also need to show that their actions were reasonable, balanced, based on the best available evidence, respectful of the rights of those concerned, the result of open minded delib- eration and respectful of the law.

Confidentiality and complaints

The reporting of actual or suspected child abuse or neglect is justifiable if its intention is to protect the child, or even others in the family, from harm. It requires disclosure of personal information to those who have a statutory duty to investigate concerns. While professionals have a general duty of confidentiality that precludes disclosure of personal information without consent, this duty is not absolute.28,31

It may be neither necessary to obtain consent to share information nor to disclose that it has occurred when there are reasonable grounds to believe that the child will be at risk of serious harm as a result. Decisions to disclose information or maintain confidentiality are matters of pro- fessional and value judgements that must be reasonable and accountable and as such open to challenge, whatever their outcome.

Paediatricians have been the objects of complaints and allegations of professional misconduct for both per- ceived over-zealous reporting and for failure to protect children. Controversial types of abuse (e.g. suffocation or fabricated or induced illness) are more likely to produce complaints, with some individuals being especially tar- geted.32 Although relatively few complaints have been

Yet such tests do not reliably identify all genetic or metabolic causes of brittle bones and take time to accom- plish, during which time crucial delays may occur in implementing a child protection plan. Nor do positive tests in themselves (e.g. the presence of minor clotting dis- orders in a child with multiple bruises) necessarily exclude abuse. Moreover, some investigations may lack diagnostic and forensic specificity and sensitivity, while others may have true or potential physical harms (e.g. radiation bur- den in skeletal surveys – detailed X-rays of the child’s bones) or psychological harms (e.g. needle phobia from repeated blood tests). Appliance of technology may there- fore be unable to provide diagnostic certainty. Repeated testing in these circumstances can be perceived as an abuse to the child perpetrated by professionals, especially where there are suspicions that illness or symptoms may be induced or fabricated.14,15

Assembling an evidence base

Although there is much unequivocal evidence that abuse and neglect occur,24 the extent to which an evidence base exists for the diagnosis of all types of abuse is less certain. It has been argued that some diagnoses lack a scientific evidence base (e.g. factitious or induced illness [FII]). If this is so, there is a duty to accumulate evidence that improves diagnostic accuracy and helps to prevent harms to all those involved. Meta-analyses25 have been useful in this respect, but have also identified conditions in which definitive evidence is lacking, for example metaphyseal fractures, and have not yet covered others (e.g. visceral injuries in children). They have highlighted the need for case controlled studies, since randomized controlled stud- ies may neither be practicable or ethical in child protec- tion and evidence gleaned from animal or adult studies may not be applicable. However, such studies, including the evaluation of the relevance, sensitivity and specificity of diagnostic investigations, entail the collection of nor- mative data about non-abused children.

Collection of personally identifiable data currently requires consent of the parties and approval by a research ethics committee. The latter may be reluctant to sanction this research because of its lack of direct benefit to those involved and perceived intrusion on personal liberties. However the collection of anonymised data, subject to stringent safeguards to prevent wrongful use, and its use in case-controlled studies may be ethically justified because of the beneficial consequences in protecting children and preventing wrongful convictions on incomplete evidence. Harris has argued that participation in such research, pro- vided there is minimal harm and invasion of privacy, also respects the obligations of individuals in society to be just and to ‘do their share’.26 If participation contributes to public good by discharging moral obligations, then parents are justified to consent to their children’s involvement on the assumption that the child, if competent to choose, would want to do what was right.

An approach that collects personally identifiable data, but with the facility to opt out has been used in the Avon Longitudinal Study of Parents and Children (ALSPAC) and has yielded epidemiological data about factors con- tributing to abuse.27 There may well be a public policy or public interest justification for studies using personally identifiable data and an appropriate mechanism for under-

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Ethical issues in child protection 211

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substantiated, individuals may have great difficulty in dealing with the adverse publicity that may accompany them, even when they have acted in good faith.29 High rates of stress, burn-out and psychological morbidity have been reported in hospital-based child protection profes- sionals.33 In consequence, difficulties in recruitment to child protection posts may pose future risks to children.17

Conversely, those parents/carers who believe themselves the victims of false accusations or unsafe convictions of child abuse face similar vilification, censure, social ostracism, with unpleasant consequences to themselves and their families.34

Although professionals must be accountable for the reliability of their interpretation of clinical facts and research findings,1 challenges should be made in a rational and appropriate manner, despite the adversarial nature of child protection hearings and the strong emotions that may be aroused. Dealing with vexatious or malicious com- plaints is more difficult, since any public response risks breaching confidentiality and refusal to comment may be misinterpreted as a desire to keep secrets or hide the truth. There may be little public realization that some com- plaints are vexatious or malicious.35 While some agencies, e.g. the Law, have mechanisms for dealing with vexatious complaints, professional regulatory bodies seem to lack them. Employing trusts do have a duty to investigate com- plaints, and should have no qualms in publicly rejecting those shown to be without foundation.

Hall has suggested that regulatory bodies should only investigate concerns about a professional’s competence or behaviour if they are raised by judges, magistrates or direc- tors of social services, or have been investigated and upheld by appropriate local multi-agency procedures.29

The Chief Medical Officer’s (CMO) recent proposals for reform of professional regulation also introduced a local mechanism for investigating professional misconduct, albeit without multi-agency input.36 Following the Appeal Court’s decision on the initial Meadow v GMC judgement, it is clear that expert witnesses are not immune from disci- plinary proceedings concerning their evidence even when it is given in good faith.38 The result of this judgment is unlikely to overcome professional reluctance to become involved in CP cases, especially as the CMO’s proposals on regulation seem to lower the burden of proof for estab- lishing professional misconduct.36 Neither will it satisfy those who feel that the only way forward is a wide-ranging public inquiry into child protection processes and proce- dures, and an opening up of the procedures of Family Courts to public scrutiny.

The court system and expert witnesses

Some cases heard by Courts, particularly those involving suffocation, poisoning, multiple fractures and brain haem- orrhage, have attracted attention and controversy espe- cially with regard to performance of experts. But many doctors have little practical understanding of the legal sys- tem and even expert witnesses can be unfamiliar with the day-to-day workings of the Court, as would most lawyers with the day-to-day practice of medicine.

Doctors encounter difficulties with the adversarial nature of the Law, its complex rules of evidence, differing burdens of proof in criminal and civil cases, and the fact

that law tends to be binary (e.g. guilty/not guilty) rather than dealing in the balancing of probabilities, variables and uncertainties that form part of clinical practice. For example, a paediatrician, by applying accumulated clinical judgement, might be so sure that abuse had occurred in a particular child such that, if there were a specific medical treatment available for abused children, s/he would use it without hesitation. To the paediatrician, therefore, the diagnosis of abuse might be ‘beyond clinical doubt’. This is rather less stringent than believing that it is beyond rea- sonable doubt that the terms of a criminal indictment are fulfilled. However, it is more stringent than the civil law’s requirement of demonstrating, on balance of probabilities, that abuse is more likely to have occurred than not.

In Court, paediatricians may find that their role as witness to fact has changed to that of expert witness (EW), a role for which they may be unprepared. Defining the duties, responsibilities and competencies of expert wit- nesses is helpful but, without better training and some form of protection for those who give evidence in good faith, is unlikely to increase numbers of witnesses or over- come reluctance to be involved. Some of these issues have been addressed by proposals to reform the EW system by transferring the function of EW in CP cases to NHS teams who will be commissioned trained and accredited for this purpose,38 but procedural matters, e.g. defining and assess- ing core competencies and training, will need resolution.

It will still be possible for either side to commission experts in the hope that they will provide support for their respective cases. While this may be in the best interests of the accused (in the sense that it upholds justice) it may not reflect what paediatricians consider the best interests of the child. Equally, separating the role of EW from those who have clinical care of the child may be desirable but logistically impossible.

There is a view that the initial conviction in the Clark case resulted from faulty judicial process rather than professional misconduct by the paediatric expert wit- ness.5,39 There may be some grounds for doubting whether an adversarial system is an appropriate one to deal with such intense personal tragedies as the death or serious injury to a child. A more inquisitorial approach to com- plex child deaths or CP cases may be justifiable, especially if it focuses on the needs of children rather than the rights of adults. The reforms suggested by the Kennedy Report on sudden unexpected deaths in infancy40 are a useful starting point, since they provide a framework for evaluat- ing complex situations where a mixture of medical, social and other factors operate. They could be applied, subject to audit and evaluation, in areas where abuse/maltreat- ment enters the differential diagnosis, but they do require a re-establishment of confidence in the system, which cur- rently may be difficult to attain. In the meantime profes- sionals need to know the rules of courts, understand the code of conduct for expert witnesses and prepare them- selves thoroughly.

An alternative approach to deeply divisive, ethically troubling issues is the concept of truth and reconciliation, involving restorative rather than adversarial or redistribu- tive justice.41 By uncovering pertinent facts, distinguishing between truth and lies and allowing for forgiveness and healing, it seeks to heal relations between opposing sides. If confronting and reckoning with the past are necessary

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in a changing world. Report of a working party. London: RCP, 2005 13 Judgments – JD (FC) (Appellant) v East Berkshire Community

Health NHS Trust and others (respondents) and two other actions (FC). 21 April 2005 UKHL 23

14 Royal College of Paediatrics and Child Health. Fabricated and Induced Illness by Carers. Report of a working party of the Royal College of Paediatrics and Child Health. London: RCPCH, 2002

15 Department of Health. Safeguarding children in whom illness is fabri- cated or induced. London: Department of Health, 2002. See http.//www.doh.gov.uk/acpc

16 Department of Health. Reference guide to consent for examination and treatment. London: The Stationery Office, 2001

17 Bannon M. Community child health in crisis. Arch Dis Child 2004;89:695–6

18 Stretch R. The duty to report child abuse in France: lessons for England? Child Fam Law Q 2003;15:139–49

19 Bell L, Tooman P. Mandatory reporting laws: a critical overview. Int J Law Fam 1994;8:337–56

20 Levi BH, Loeben G. Index of suspicion: feeling not believing. Theor Med Bioeth 2004;25:277–310

21 Diaz A, Neal WP, Nucci AT, Ludmer P, Bitterman J, Edwards S. Legal and ethical issues facing adolescent health care professionals. Mt Sinai J Med 2004;71:181–5

22 Budai P. Mandatory reporting of child abuse: is it in the best interest of the child? Aust N Z J Psychiatry 1996;30:794–804

23 The Children Act, 2004. See ss11 (1)(f), (2)(a) and ss12 (6)(b), (7)(a)

24 Chadwick DL. The evidence base in child protection litigation. BMJ 2006;333:160–1

25 www.core-info.cf.ac.uk 26 Harris J. Scientific research is a moral duty. J Med Ethics

2005;31:242–8 27 Avon Longitudinal Study of Parents and Children (ALSPAC). See

http://www.alspac.bristol.ac.uk/pub/index.shtml 28 Royal College of Paediatrics and Child Health. Responsibilities of doc-

tors in Child protection cases with regard to Confidentiality. London: RCPCH, 2004

29 Hall DM. Is protecting children bad for your health? Arch Dis Child 2005;90:1105–6

30 Bannon MJ, Carter YH. Paediatricians and child protection: the need for effective education and training. Arch Dis Child 2003;88:560–2

31 General Medical Council. Confidentiality: Protecting and providing information. London: GMC, 2002. See www.gmc-uk.org.

32 Marcovitch H. Diagnose and be damned. BMJ 1999;319:1376–7 33 Bennet S, Plint A, Clifford TJ. Burnout, psychological morbidity, job

satisfaction, and stress: a survey of Canadian hospital based child protection professionals. Arch Dis Child 2005;90:1112–16

34 MAMA (Mothers Against Munchausen syndrome by proxy Allegations). See www.msbp.com

35 Marcovitch H. GMC must recognise and deal with vexatious com- plaints fast. BMJ 2002;324:167

36 Good Doctors Safer Patients. The Chief Medical Officer’s review of medical regulation following Dame Janet Smith’s inquiry into the circumstances of the murders committed by Dr Harold Shipman. See http.//www.dh.gov.uk/publications/policy and guidance articles

37 General Medical Council v Meadow [2006] EWCA Civ 1390 (26 October 2006)

38 Bearing Good Witness: Proposals for reforming the delivery of medical expert evidence in family law cases – a consultation. See http:// www.dh.gov.uk/Consultations/LiveConsultations/fs/en

39 Hey EN. Suspected child abuse: the potential for justice to miscarry. BMJ 2003;327:299–300

40 The report of a working group convened by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health. Sudden unexpected death in infancy: a multi-agency protocol for care and investigation. London: The Royal College of Pathologists and the Royal College of Paediatrics and Child Health, 2004

41 Avruch K, Vejarano B. Truth and reconciliation commissions: a review essay and annotated bibliography. Soc Justice Anthropol Peace Hum Right 2001;2:47–108

for transition from conflict, resentment and tension, there may be ethical justifications for trying such an approach in child protection, or in modifying our current adversarial approach.

Conclusion

The investigation and management of child protection concerns will always be controversial and difficult. However, the obligation to protect the weak and vulnera- ble from abuse, neglect and exploitation is fundamental to civilized societies. Given that diagnoses are based on bal- ancing probabilities and uncertainties there is always a potential for injustice to all concerned. The tendency to blame experts for what may be system failures has arguably resulted in CP becoming a high-risk area of paediatrics with a reluctance of professionals to become involved.

The current adversarial approach, with its heroes, vil- lains and victims, hypotheses and counter-hypotheses, does not promote greater understanding and may not be in the best interests of children. Potential elements of a revised social contract for the effective protection of chil- dren might include the following: a duty of care that ade- quately addresses the primacy of the child’s welfare; the acquisition of a sound evidence base; professional trans- parency and accountability (but with protection from malicious and vexatious complaints); and a shift emphasis towards a more inquisitorial system that embraced the principles of truth and reconciliation.

It is time for a frank and informed discussion of the issues that arise in child protection, which might lead to redefining the moral contract between professionals and society for the benefit of children. This is surely what chil- dren want and deserve.

References

1 Craft AW, Hall DM. Munchausen syndrome by proxy and sudden infant death. BMJ 2004;328:1309–12

2 Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the dis- tinction from child abuse and the recognition of a variant form. Am J Med Genet 1993;45:187–92

3 Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001;124:1299–306

4 The Victoria Climbie Inquiry. Report of an inquiry by Lord Lamming. Cm 5730. London: The Stationery Office, 2003. See http://www. victoria-climbie-inquiry.org.uk/index.htm

5 Horton R. A dismal and dangerous verdict against Roy Meadow. Lancet 2005;366:277–8

6 Kmietowicz Z. Complaints against doctors in child protection work have increased fivefold. BMJ 2002;324:167

7 Dyer O. Doctors reluctant to work on child protection committees. BMJ 2004;328:307

8 Chantler C, Doyal L. Medical ethics: the duties of care in principle and practice. In: Powers M, Harris N, Lockhart-Miriams A, eds. Clinical Negligence. London: Butterworths, 1995

9 General Medical Council. The duties of a doctor registered with the General Medical Council. London: GMC, 2002

10 Royal College of Paediatrics and Child Health. Good medical practice in Paediatrics and Child Health: duties and responsibilities of paediatri- cians. London: RCPCH, 2002

11 Montgomery J. Health Care Law. Oxford: Oxford University Press, 2004

12 Royal College of Physicians. Doctors in society: Medical professionalism

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