Sexual Abuse: An Ethical Dilemma of Autonomy vs. Beneficence and the Role of Healthcare Providers in a Community Setting

Introduction

By virtue of their professions, health workers who deal directly with human lives (such as doctors and nurses) are prone to questioning their decisions and practices, especially from an ethical standpoint. To practise competently, one needs to be equipped with knowledge pertaining to the discipline of bioethics. To elucidate this point, this article will examine a child sexual abuse (CSA) case from a bioethical lens and analyse it through the MORAL ethical decision-making model of Patricia Chricham.

Case Scenario

While working as a Student Counsellor and practising nurse at a low-income, co-education higher secondary school in Karachi, I encountered a situation which compelled me to reflect on the appropriateness of the decision/action that was taken at that time. A Year-I student, aged 16 and from a Sindhi* family, was referred to me by her teacher for not performing well academically. She reported problems such as headache, insomnia and occasionally nightmares, resulting in frequent absenteeism. Eventually, in private sessions with her, I found that a year ago she has been sexually abused by one of her family friends in his thirties. Her whole body was trembling and her tearful red eyes were conveying the severity of mental trauma she was experiencing. She had not shared this incident with anyone before me. She was offered to have a meeting with her parents in my presence as counsellor so that she could share that incident with them in a supportive and safe environment. She refused this suggestion, believing that her parents would never understand her and would instead blame her for the incident. Her sister was a medical doctor and ideally could have been a trustworthy and appropriate confidante, but the victim did not give permission to approach her sister either. This anxiety had put her in great agony. With the girl’s consent and without disclosing her identity, I explained the situation to the school principal in order to take his viewpoint of the problem. The principal’s involvement helped in reaching the decision to respect the girl’s wish of not disclosing the incident to her family. Finally, I referred her for further medical consultancy. However, since I was professionally obliged to share all my cases with my Department Head, I took the girl’s consent to discuss this issue without revealing her identity. I documented this case in a separate file that was kept in a locked drawer.

This scenario is emblematic of a real ethical dilemma, i.e., whether or not to disclose information about this incident to the girl’s parents. If the girl’s autonomy was respected, then she might be exposed to further abuse as she would not get sufficient support, guidance and protection from her family; whereas if the incident was disclosed to her parents, then her autonomy, which is her fundamental right, would be violated. In the view of some experts, the principles of autonomy and beneficence can conflict with each other (Gladys 1992). Some suggest that despite the beneficent role of an intervention, doing so may still be wrong because it violates the patient’s autonomy (Fry and Veatch 1987). In light of the incident narrated above, the aim of this article is to examine concepts of autonomy versus beneficence.

Child Sexual Abuse (CSA) and Socio-Cultural Context of CSA in Pakistan

Literature shows that the incidence of CSA may never be known precisely. However, global estimates of CSA using meta-analysis reveal figures ranging from 7.9% of men and 19.7% of women suffering some form of sexual abuse prior to the age of 18 (Pereda et al. 2009). Another meta-analytic study reports an overall global estimate of 12.7% (Stoltenborgh 2011). Globally, 44% of sexual abuse occurs between the ages of 13 and 16 and 68% of these teenagers were abused by close friends or relatives (Medical Study News 2004). In Pakistan, a total of 2,595 cases of CSA were reported in 2010, i.e., approximately seven children are sexually...