Intimate partner violence in Pakistan: Ethical implications in an emergency case

Introduction

Intimate partner violence occurs globally in all religious, cultural, and socioeconomic settings, and commonly involves physical, psychological, or sexual harm done within an intimate relationship. ¹ Women are overwhelmingly victimized in these relationships due to dominant, controlling, and aggressive behavior of their male partners. ¹ Such violence against women is a growing pandemic where 1 in 3 women has tolerated either verbal, physical, and psychological abuse at least once in her lifetime by her partner, according to World Health Organization. ²

In Pakistan, intimate partner violence against women stretches across different educational and cultural backgrounds. ³ As per 2017−2018 Pakistan Demographic and Health Survey, 28% of women aged between 15 and 49 have experienced physical violence and 6% have undergone sexual violence at some time in their lives. ⁴ Spousal violence in Pakistan is a major public health concern, owing to various factors, such as a patriarchal society, low social status of women, financial difficulties, insufficient protection by laws, and decreased literacy rate.^5,6

During 2017−2018, about 34% of married women across Pakistan were victims of physical, sexual, or emotional violence by their husbands. ⁴ Overall, emotional or psychological violence was most common where at least 26% of married women were affected, followed by 23% physical violence and 5% sexual domestic violence. ⁴ In the same year, 7% of pregnant women in Pakistan have experienced physical violence, and 3% have reported pregnancy loss or other health issues due to this. ⁴ According to the Global Gender Gap Index 2018, Pakistan is the sixth most insecure country in the world for women. ⁷

If we assess globally, the best coping strategies for women experiencing intimate partner violence are quitting the relationship with the abuser, quietly accepting the violence, or self-defense. ⁸ However, in Pakistan, 56% of such victims never seek help or support. ⁴ Out of this, 24% victimized women do not consider their domestic violence to be a serious issue, 15% are ashamed or embarrassed, 12% are worried about their own family's reputation and 9% fear the consequent threats and violence if they sought help. ⁴ Throughout history, the Pakistani legislature has favored the cultural bias against women despite making frequent efforts to protect them optimally. ⁹ Under a societal construct where most women in Pakistan who do not show help-seeking behavior and end up in hospital emergency wards, it becomes an ethical dilemma for caregivers to not only justifiably treat the patient but also report such cases responsibly.

This case report highlights a similar situation where various ethical questions were raised, and investigates various difficulties seen in the setting of intimate partner violence at a tertiary care public hospital in Karachi, Pakistan. The aim is to explore and assess the challenges, and how they can be overcome in the social and legal context while ensuring maximum safety and support of the domestic violence victim.

Case study

Few years ago during summertime, around midnight, a 20-year-old female was brought to the emergency department of a tertiary care public hospital in Karachi, Pakistan by her husband and 8-month old daughter.

The patient complained of intolerable pain in her left wrist The attending physician performed complete physical examination, and noticed bruising, swelling, tenderness, and visible deformity of her left wrist joint. He also noticed bruising and mild swelling around her left eye, along with some scratch marks on both arms. Her left cheek had evident petechial hemorrhages with redness and bruising of her left ear.

Complete ophthalmologic and ear examination did not reveal any functional deficits; however, there were signs of gingival bleeding and poor dental hygiene. Chest and abdominal examination were unremarkable. The patient was well-oriented but in much distress. She was reluctant about revealing any information about her clinical history. She was clearly trying to hold back her tears and was emotionally wrecked. In such a situation where the patient is fully alert and oriented but unable to provide her history, it becomes an ethical question on whether the doctors should wait and insist upon taking the history directly from the patient or should they rely upon the hurried history provided by her attendant.

In this case, her husband provided the history of falling on wet floor at home. The doctors proceeded to obtain further history from the husband. During this, he was also reluctant to confidently answer many questions and seemed confused. His only immediate concern was to get urgent treatment for his wife, so they can leave the hospital soonest The medical staff observed the husband’s short-tempered behavior when he was talking to his wife in the emergency room, and she was quite afraid of him.

Upon asking the husband, the doctors learned that this family originally migrated from a rural area and belongs to a poor socioeconomic background. When asked about the trauma on his wife's face, the husband had no reliable answer. He only insisted on the story of falling on a wet floor.

Doctors proceeded to perform an X-ray of wrist and routine blood workup along with a computed tomography (CT) scan of head in accordance with the patient's history of recent trauma. The husband immediately refused the CT scan for his wife, owing to the fact that neither he has the money, nor does he find this test relevant to his wife's active complaint of wrist pain. Based on his judgment and financial difficulties, whether it is ethically permissible for the husband to refuse CT scan for his wife or not is another dilemma that this case entails.

The diagnosis of wrist fracture was confirmed on the X-ray. The patient has advised hospital admission for monitoring and treatment. However, the husband categorically denied hospital admission, reasoning that he has to go to work at a bakery in the morning and there is no one to look after their 8-month old daughter except his wife.

The medical staff discussed this vague case with the Head Resident because the nature of described trauma does not meet the clinical presentation of this patient. It was possibly a case of domestic violence. To confirm this, the husband was sent outside to buy the medication, and two female nurses tried to speak with the patient in a safe and private setting.

If the patient still refused to reveal anything due to fear, it is questionable for doctors to notify the police based on their own likelihood of domestic violence. Most hospitals have a medico-legal section where any assault or foul play can be directly reported by the doctors for further inspection. Was this case eligible for medico-legal investigation or not, is another burning question at this time.

Since the patient spoke a regional language, there was a communication barrier among the Urdu-speaking nurses and the patient while obtaining the history. They were, however, able to grasp the positive history of physical and verbal abuse. The patient also admitted that the fracture was secondary to a fall after her husband pushed her. This terrified patient further requested the doctors and nurses not to call any legal authorities, and clearly stated that she will not admit any violence in front of police.

Despite counseling her about the social support from non-governmental organisations and legal protection, she categorically denied any help in this regard. When asked about her own family, she told them that her father and brother have never listened to her complaints in the past It was understandable that she knew her circumstances, but did not expect any support from her family because she grew up watching her own father abuse her mother.

The communication among the nurses and patient was not documented. Whether this communication required any documentation in the patient's medical record is another ethical challenge that this case study highlights. The case also went unreported to the authorities as the emergency room (ER) medical staff unanimously agreed that our social and legal system does not provide sufficient protection and support to such victims and the reporting doctors.

A splint was applied to the patient left wrist, analgesic medicine was prescribed and patient was discharged right away. “Left against medical advice” was documented on the patient's file as a safeguard to malpractise, and the patient has advised a follow-up visit in the outpatient clinic after 4 days.

Discussion

The case above is an example of various issues faced routinely by ER doctors in Pakistan. It highlights many ethical challenges and raises questions that revolve around intimate partner violence, which has been a constant public health concern globally.

The major ethical dilemma in this case is reporting a potentially criminal case of domestic violence to the authorities. Physicians have a legal and professional obligation to maintain the confidentiality of patient information. ¹⁰ There are situations, however, where physicians are either required or permitted to report particular events to the law enforcement agency. Mandatory reporting of domestic violence to law enforcement by doctors varies according to the country's legal system and clinical circumstances. The doctors in this case tried to confirm domestic violence from the patient, despite the fact that she was initially reluctant to even provide her own history of trauma.

Unlike regular history taking, discussing about abuse or violence is quite challenging for both doctors and patients because it involves trust on the physician and safety of respondent. In such a situation, it is best to first provide emergent care to the patient to build rapport and confidence between both parties. This allows ample time for the patient to gradually feel comfortable enough to start opening up about his or her physical or emotional suffering.

If the patient still continues to hide the details, it is the ethical responsibility of the doctor to continue providing emergency care, regardless. ¹¹ The idea stems from the ethical principle of providing maximum benefit and minimal harm, and it holds true for such cases.

Similarly, when the patient confirmed verbal and physical violence but refused to admit it to the police, the doctors respected the patient's autonomy because it is their moral obligation. This case, however, puts doctors under major ethical dilemma because they have to weigh justice, beneficence, nonmaleficence, and respect for patient's autonomy, all at one time. They clearly want justice for the patient but cannot breach her autonomy, especially after knowing that the patient understands her current circumstances and possible consequences if she reported this case.

Considering the social and cultural norms, doctors decided to respect her informed decision of refusing any legal help. Hence, not involving the medico-legal team might be the right call here.

This case puts patient confidentiality under great emphasis, which is a prime responsibility of every physician and is well-articulated in Hippocratic oath, “What I may see or hear in the course of the treatment or even outside of the treatment with regard to the life of the person I will keep to myself.” ¹²

While this case evidently contains foul play from the husband's side, it is equally important to respect patient confidentiality. Sharing her information can lead to further agitation in her family, and might escalate her husband's violence. Additionally, if he was openly confronted about domestic violence by the doctors or put under legal investigation, he might not even bring her to a healthcare facility next time. Therefore, the doctor's decision to withhold patient information and leave the communication between nurses and patient undocumented might be the right decision in this case, largely to ensure patient safety.

In contrast, if the patient had decided to report this violence, the doctors would fully support her in documenting and reporting it to the police, and would ensure her safety and care in all possible ways. Education is one of the most important determinant in health-seeking behavior, ¹³ and the doctors in this case educated and counseled her about her options. Since she decided against reporting her domestic violence, the doctors continued to respect her autonomy and confidentiality in her own best interest.

It can be argued that the patient's admittance of domestic violence should have been documented for future reference, in case she is brought to another hospital with severe injuries at another time. Doctors could discuss the need of documentation with this patient, while also ensuring that all her information will be kept confidential until another healthcare worker absolutely requires it.

It has been generally observed that documenting patient information, such as patient data in computer files, rooms, or cabinets, can be quite insecure in most public hospitals in developing countries. There should be proper protocols and policies for safer documentation to regulate better healthcare confidentiality, so that extremely sensitive patient information will not go undocumented in fear that it might unknowingly breach confidentiality.

Lastly, the case also brings up another ethical challenge of Pakistani society where the husband can take decision for the wife's health, simply based on his own judgment and financial status.

In medical ethics, the health interest of the patient is far superior than the financial arrangements and social status, ¹⁴ and this justifies the emergent need of a head CT scan and hospital admission for the patient described above. However, in developing countries like Pakistan, it is generally a social obligation for the husband to make decisions and provide care for the family, including the best medical treatment. The wife, on the other hand, is dependent upon her husband in most matters.

Given this social construct, it is understandable that the husband took decision for his wife, especially because she was hesitant to decide anything for herself. The brief negotiation between husband and doctor justifies that the doctors explained the harms and benefits of both the head CT scan and hospital admission, but he refused both.

The refusal of hospital admission and cost of CT scan can be judged under the utilitarian approach, since most of the bakery workers in the city work under daily wages. Additionally, the husband also insisted on taking the wife home because there was no one to look after their infant daughter. Under these social circumstances and logical reasoning, it was morally justified to follow the husband's decision.

Conclusion

The ethical values and disciplines of healthcare in developing countries require strict adherence and proactive approach, especially for sensitive yet common matters such as domestic violence. The healthcare providers are sought not only for physical injuries, but should be trained to pick the underlying social and domestic problems that lead to these injuries. They should also be widely equipped to provide support services and additional help, whenever a need arises.

In this particular case, the need to document all patient communication was vital in preventing future misdiagnosis and misunderstandings. Similarly, the entire family could be counseled about family therapy or psychotherapy, so the husband can learn anger management, the wife can recover from her psychological stress and their daughter can be brought up in a peaceful environment.

Healthcare providers at all levels should be aware of their legal duties and community roles. A direct link to concerned authorities should be maintained with well-defined rules so that no such cases go unaddressed in any health setup.