What is an act of omission in healthcare

An act of omission

To avoid a certain behavior may sometimes be judged right or wrong. As mentioned earlier, there are ambiguities in describing just what it is that is not being done. If one does not contribute to charity, is that stinginess or an effort to encourage sturdy independence in the poor? If an eligible voter decides not to vote, that act of omission may be part of what decides an election.

A classical position, that of the Stoics, held that one should have no interest in matters that are not under personal control. One’s body, property, reputation, and office depend on external matters, and so should be considered of no importance. If something is of no importance then one may properly omit any action in that matter. One’s own thoughts, however, were taken to be personal decisions and so were of moral significance. For everything else, the Stoics held that one should be indifferent to anything not under one’s control.

Standards of Care

Occasionally, a disgruntled party may allege that a professional mishandled or mismanaged confidential information in ways that were harmful. For example, a physician’s patient may allege that the physician disclosed sensitive health information about the patient without authorization to the patient’s spouse and that this disclosure had an adverse impact on the relationship. An accountant’s client may allege that the accountant disclosed confidential information inappropriately to a government tax official that resulted in significant financial harm to the client. A mental health counselor’s client may allege that the counselor disclosed unauthorized information to a police officer that led to the client’s arrest.

People who believe that they have been harmed by an improper disclosure of confidential information may file lawsuits that seek some kind of redress. These negligence claims typically allege that the defendant failed to perform in a manner consistent with the legal concept of standard of care – that is, the way an ordinary, reasonable, and prudent professional would act in the same or similar circumstances. Negligence can occur as a result of a professional’s active violation of someone’s rights by disclosing confidential information without authorization (in legal terms, acts of commission or misfeasance) or a professional’s failure to disclose confidential information when it should have been disclosed, for example, to prevent harm to a third party (acts of omission or nonfeasance). Definitions of ‘negligence’ typically include four elements:

At the time of the alleged negligence, a legal duty existed between the professional and the person who claims to have been harmed (e.g., the duty that a physician, nurse, or mental health counselor would owe to his or her patient or client).

The professional was derelict in that duty, either through an omission (e.g., failing to notify government child welfare or elder welfare officials about suspected abuse or neglect, as required by law) or through an action that occurred, or commission (e.g., disclosing confidential information to law enforcement officials or a family member without authorization).

The plaintiff or complainant suffered some harm or injury (job loss, marital discord, housing eviction, arrest, or emotional harm that allegedly resulted from the mismanagement of confidential information).

The professional’s dereliction of duty was the direct and proximate cause of the harm or injury (e.g., the injuries or harm were the result of the professional’s unauthorized disclosure of confidential information).

In order to protect patients, clients, colleagues, and other relevant parties, professionals should be very familiar with prevailing standards of care in their respective profession. Standards of care reflect prevailing professional opinion about what constitutes ordinary, reasonable, and prudent practice, as articulated in codes of ethics, reputable professional literature, policies and guidelines established by recognized professional associations, agency and organizational policies, expert testimony, and pertinent legal guidelines.

To minimize ethics-related risk, professionals should conduct a comprehensive assessment, or audit, of their confidentiality practices, policies, and procedures. Ideally, professionals should carefully examine the ways in which they manage confidential information and assess the adequacy of organizational policies and procedures in light of current standards of care. This kind of ethics audit – designed to assess whether there are no, minimal, moderate, or serious confidentiality risks – is an effective way to enhance protection of all parties involved.

II Maltreatment Subtype Classification

Although standardized methods for classifying maltreatment subtypes have been developed, they are not utilized consistently (Barnett, Manly, & Cicchetti, 1993; National Center on Child Abuse and Neglect, 1988). A standard method of classification is important because differences between definitions utilized in research and by Child Protective Services continue to make it difficult to interpret the results of research, to determine which children are eligible for services, and to ascertain the effectiveness of services (Aber & Cicchetti, 1984; Cicchetti & Rizley, 1981; Runyan et al., 2005). In the policy arena, each State defines maltreatment and its subtypes differently, but all base their definitions on a set of federal minimum guidelines. The Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. §5106g) defines child abuse and neglect as “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act of failure to act which presents an imminent risk of serious harm.”

Similar to the error distinction made in Chapter 5, the major difference between abuse and neglect is that abuse is an act of commission and neglect is an act of omission on the part of the caregiver (Connell-Carrick & Scannapieco, 2006; Valentino, Cicchetti, Rogosch, & Toth, 2008). Neglect is often defined as a failure to provide for a dependent child's basic essential needs whether those needs be physical, emotional, or intellectual (Mayer, Lavergne, Tourigny, & Wright, 2007), whereas abuse is an act resulting in physical injury to the child (Scannapieco & Connell-Carrick, 2005). In general, there are four classifications of maltreatment that are recognized by all States: neglect, physical abuse, sexual abuse, and psychological maltreatment.

Classification of types of abuse for research purposes is difficult because different types of abuse occur at different ages and co-occurrence of subtypes is common (Manly, 2005; Bolger, Patterson, & Kuperschmidt, 1998). For example, a child who is physically abused may also be psychologically abused; a child who is physically abused in the early years may be sexually abused as an adolescent. The Maltreatment Classification System (MCS; Barnett et al., 1993) offers a nosological system in which the subtype is identified based on operational definitions. Because children can be classified as having experienced multiple subtypes of maltreatment, a hierarchical standard related to the degree to which the maltreatment deviates from typical caregiving can then be utilized. One method of classifying children based on their experiences involves assigning a primary subtype designation based on the degree of deviation from societal norms. For example, a child who is sexually abused and psychologically maltreated would be classified as sexually abused. Although the hierarchy method cannot accurately portray a child with several maltreatment subtypes, it has been shown to more accurately predict the developmental outcomes of abuse and neglect when compared to the maltreatment characterizations assigned by Child Protective Services in five different states (Runyan et al., 2005). (The MCS also provides other methods for classifying maltreatment that incorporate comorbid subtypes—see Manly, 2005.)

2 Managing Childhood Maltreatment in Singapore

Singapore is an independent island state in Southeast Asia with a total population of 5.6 million according to Singapore Department of Statistics (DOS, 2017b). The management of child protection cases in Singapore is guided by interministry child abuse protocols first developed in 1999 and the National Standards for Protection of Children that was introduced in 2002 by the then Ministry of Community Development, Youth and Sports (known today as Ministry of Social and Family Development, MSF). Similar to how WHO has conceptualised maltreatment (Butchart et al., 2006), childhood maltreatment in Singapore is broadly defined as any act of omission or commission by a caregiver that results in actual or potential harm to children and young persons (CYP) under 16 years (MSF, 2016). The standards set a framework for different systems, such as the judicial system, police, healthcare services, schools, and child protection agencies, to handle child protection cases.

The Child Protective Service (CPS) of the Ministry of Social and Family Development (MSF) oversees the investigation of child abuse allegations and the subsequent protection of children. When a case is referred to CPS, the intake unit would assess, using a tool, if the case meets the threshold for statutory intervention. If it does, the case is then referred to the investigation unit, which conducts a social investigation on the case and assesses the immediate safety of the child. The investigation officer also assesses the level of intervention that should be accorded to the family and if there is a necessity for the application of a Care and Protection Order to ensure the necessary safeguards to keep the CYP safe. Following the social investigation and assessment of the likelihood of future harm to the CYP, the family is then referred for services. This is to either suitable community services or CPS’ intervention unit, for ongoing intervention to address needs to ensure the safety of the child.

The legal protection for children in Singapore is guided mainly by the Children and Young Persons Act, which is largely based on child protection legislations in the United Kingdom. However, cross-cultural studies have shown that the meaning of child maltreatment varies across Western and Asian cultures (Deater-Deckard & Dodge, 1997). For example, strict discipline (such as caning) is viewed as a sign of parental concern and involvement rather than child abuse in Asian societies (Elliott, Tong, & Tan, 1997; Lau, Liu, Yu, & Wong, 1999). Such differences in the sociocultural context will not only change the antecedents but also moderate the effects of childhood maltreatment (Gershoff, 2002). For example, it was found that the Singapore public strongly disapproved of sexual abuse (Elliott et al., 1997), and accordingly, Singaporean women with childhood sexual abuse history reported worse psychological adjustment compared with women from the United States with a sexual abuse history (Back et al., 2003). Additionally, societal perceptions are subjected to change over time. Following on the above example of strict discipline in Asian societies, the perspective of physical discipline in Singapore is also changing. In 2004, a study by the Singapore Institute of Mental Health demonstrated that fewer Singaporean parents are resorting to physical discipline, with 68% out of the 230 parents revealing that they used reasoning alone as a form of parental discipline (Lee, 2004). These results suggest the importance of cultural sensitivity in CPS studies.

Definitions and Types of Violence

Public health experts define violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.

The definition associates intentionality with the committing of the act itself, irrespective of the outcome it produces. Excluded from the definition are unintentional incidents – such as most traffic injuries and burns. The inclusion of the word ‘power’, in addition to the phrase ‘use of physical force’, broadens the nature of a violent act and expands the conventional understanding of violence to include those acts that result from relationships where a perpetrator has more power then the victim (e.g., parent–child relationships, relationships between armed perpetrators and unarmed victims), including threats and intimidation. The ‘use of power’ also serves to include neglect or acts of omission, in addition to the more obvious violent acts of commission. Thus, the ‘use of physical force or power’ should be understood to include neglect and all types of physical, sexual, and psychological abuse as well as suicide and other self-abusive acts.

The definition includes a broad range of outcomes – including psychological harm, deprivation, and maldevelopment. This reflects a growing recognition among researchers and practitioners to include violence that does not necessarily result in injury or death, but nonetheless poses a substantial burden on individuals, families, communities, and healthcare systems. Many forms of violence against women, children, and the elderly, for instance, can result in physical, psychological, and social problems that do not necessarily lead to injury, disability, or death. These consequences can be immediate, as well as latent, and can last for years after the initial abuse. Defining outcomes solely in terms of injury or death thus limits the understanding of the full impact of violence on individuals, communities, and society at large.

In addition to defining violence, it is important to understand the different types of violence and the important links between them. The typology presented in Figure 2 is the most comprehensive typology to date. The typology divides violence into three broad categories according to characteristics of those committing the violent act: self-directed violence, interpersonal violence, and collective violence. This initial categorization differentiates between violence a person inflicts upon himself or herself, violence inflicted by another individual or by a small group of individuals, and violence inflicted by larger groups such as nation-states.

These three broad categories are each divided further to reflect more specific types of violence. Self-directed violence is subdivided into suicidal behavior and self-abuse (e.g., acts of self-mutilation). Interpersonal violence is divided into family and partner violence largely occurring in the home, though not exclusively; and community violence which includes violence between individuals who are unrelated and who may or may not know each other, generally taking place outside the home (e.g., youth violence, sexual assault by strangers, and violence in institutional settings like schools, workplaces, prisons, and nursing homes). Collective violence is divided into social, political, and economic violence. It can take a variety of forms such as wars, terrorism and other violent political conflicts that occur within or between nation-states, genocide, state-perpetrated torture or other human rights abuses, and organized violent crime. The typology also illustrates the nature of violent acts, which can be physical, sexual, psychological, or involving deprivation or neglect.

Child Neglect

Despite inconsistencies in state definitions, generally neglect is defined as physical (refusal or delay in seeking health care; inadequate supervision, hygiene, nutrition, and safety), emotional (failure to provide adequate attention, warmth, and affection and/or exposure to substance abuse or violence), and/or educational (failure to promote education or school attendance and inattention to special education needs) omissions in parenting. Recent evidence suggests that these neglectful behaviors fall into three distinct categories: physical, psychological, and environmental neglect. Child neglect has been grossly underresearched in the United States, leading to the phrase neglect of neglect. Throughout the literature, child abuse and neglect often are grouped together despite the clear distinction between acts of commission and those of omission. Whereas many people think of child abuse when considering child maltreatment, child neglect is in fact more prevalent, costly, and detrimental.

Anthropogenic Climate Change and Moral Responsibility

According to the Working Group I report in AR4, human emissions of greenhouse gasses have already resulted in climate changes, and the predictions of future changes are of such severe character that they will evidently cause harm to both humans and the environment. The predicted impacts of anthropogenic climate change for the near and distant future have given rise to discussion regarding whether a moral responsibility can be assigned to current generations of people for the harm caused due to past and present greenhouse gas emissions. Moral responsibility can be described as a response to matters of facts, involving a normative prescription of blame or fault. In this context, it is the scientific outline of anthropogenic climate change that is brought forward as the reason for prescribing a moral obligation to compensate for harm caused by establishing practical measures to ensure mitigation and adaptation. Assigning a moral responsibility on the basis of the causal relation between human emissions of greenhouse gasses and the climate changes taking place is not without complications, however: Who is to be blamed? To what extent can present generations of people be held liable for climate changes now and in the future?

Most individual actions that involve emission of greenhouse gasses, such as driving a car or using electricity, are not done with the intention to cause harm and may not even be anticipated by the individual as contributing to climate change. It can, however, be argued that the individual contribution to greenhouse gas emission is to be interpreted as a form of omission. Whether one should be made responsible for acts of omission in relation to climate change depends on the ethical approach taken. A deontological approach that judges the act on the basis of the intention with which the act was carried out may be less likely to claim a person responsible in such cases, whereas a consequentialist approach that judges the act on the outcome does not distinguish between intended actions and actions by omission and is therefore likely to claim that each individual is morally responsible for the harm caused to the climate through his or her contribution to greenhouse gas emissions.

Assigning moral responsibility to the individual in this way, however, is questionable because it is arguably less the individual’s contribution but, rather, the contributions of all to greenhouse gas emissions that can be said to cause harm by contributing to the global warming process and the climate changes that follow from it.

Instead, it may be reasonable to assign responsibility collectively by making groups, rather than individuals, responsible for the common contribution to harm. The idea of collective moral responsibility is reflected in the Kyoto Protocol, which takes as its starting point that developed countries are responsible for significantly larger emissions of greenhouse gasses per capita in the past and present than are developing countries. The causal relation between greenhouse gas emission and climate change together with the size of the contribution of greenhouse gas in the past and present is used as an argument for assigning a moral and legal responsibility to these countries in terms of an obligation to establish practical mitigation and adaptation measures. The collective responsibility described here is founded in the idea of justice, delineated in the United Nations Framework Convention on Climate Change (UNFCCC). The convention reflects the idea of distributive justice, which is an aspect of virtue ethics commonly applied in relation to climate change. It is reflected in the Climate Convention’s emphasis on fairness and equity as the basic principles to be pursued in the distribution of goods and burdens between countries. A different outline of collective responsibility is reflected in the principle of sustainability, also outlined in the UNFCCC, which suggests a collective responsibility of current generations to ensure minimal harm for future generations. This relates to another aspect of justice commonly associated with climate change, namely the idea of intergenerational justice, and it gives rise to the question as to how far the responsibility stretches and whether it is possible to assign a moral responsibility in the present for future generations. This question is particularly relevant in the context of mitigation and is explored more in-depth later.

What does omission mean in healthcare?

What is an act of omission?

What is an error of omission in healthcare?

What's the difference between omission and commission?