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When Indecision Is a Decision and Inaction Is an Action

Davis, Peter J. MD

doi: 10.1213/ANE.0b013e3182460ace
Editorials: Editorials

From the Departments of Anesthesiology and Pediatrics, Pittsburgh School of Medicine, and Department of Anesthesiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the author.

Address correspondence to Peter J. Davis, MD, Department of Anesthesiology, Children's Hospital of Pittsburgh of UPMC 4401 Penn Avenue, Pittsburgh, PA 15224-1529. Address e-mail to

Accepted December 7, 2011

Child abuse is a crime. Reportedly, between 4% and 16% of children are physically abused and 10% are psychologically abused or neglected annually. During childhood, 5% to 10% of girls and up to 5% of boys are exposed to penetrating sexual abuse. About 8% of suspected cases of child abuse are reported by health care professionals. In 2009, child protective service agencies received an estimated 3.3 million referrals involving 6 million children.1,a Although official rates for substantiated child abuse underestimate its true incidence, child abuse is a problem that is pervasive, extending deep into the fabric of society, and transcending all socioeconomic levels.

In this issue of Anesthesia & Analgesia, Dr. Harvey agonizes over a decision to become involved when confronted with the possibility that the child he is to anesthetize may be a victim of abuse.2 Unfortunately, suspected child abuse is frequently encountered in the practice of pediatric anesthesia. For the pediatric anesthesiologist, the decision of what to do or not do is made in the context of a clinician facing the demands of a busy operating room schedule. Acting to protect the child triggers a cascade of events that grinds the schedule to a halt. Raising concerns invites scrutiny of the clinician's judgment. Not reporting the suspicion is frequently rationalized by either bystander blindness (many people witness an event but no one reports it because someone else will do it) or, worse, motivational blindness (not seeing what is in a person's interest not to see). Whether it is bystander or motivational blindness, the results are the same: indecision is a decision, inaction is an action, and both action and inaction have consequences.

In his essay, Dr. Harvey recounts his unsettled thoughts and inner self-doubt as he struggles to balance the possibility of wrongly accusing an individual of a repugnant, heinous act with the morally compelling imperative to protect a child from further abuse. If he is wrong, will he have destroyed the parent–child bond? If he is wrong, will he have tarnished the reputation of a kind and caring father? If he is wrong, will he, Dr. Harvey, be viewed as a pariah, an unreliable clinician, a colleague with poor judgment? However, not acting, not reporting possible abuse, requires ignoring the possibility that his inaction will allow further unthinkable acts to be perpetrated on a young child, a person incapable of fending for himself or herself.

Indecision and inaction are common responses to allegations of the sexual abuse of children. Recent headlines have focused on allegations of the sexual abuse of minors by a football coordinator at Pennsylvania State University. The story riveted the nation as the world tried to understand how seemingly good people at an institution of higher learning made bad decisions, or chose to make no decision. Public outrage led to the firing of an iconic football coach, the resignation of the university president, indictments of the university's former athletic director and the vice present of finance and business for perjury, and the investigation of what officials knew, and did not know, about the sexual abuse of minors.

The respected and trusted leaders at Penn State looked the other way, abrogated their responsibilities, and more children were harmed. Indecision was a decision. Inaction was an action. Both are unacceptable. Dr. Harvey, an anesthesiologist, is a role model for the former president of Penn State, and for medical colleagues facing this terrible dilemma: despite the pain, the self-doubt, the risk of criticism from peers, and the possible consequences of error, do the right thing. The child comes first.

As we reflect on Dr. Harvey's decisions and actions, the words of the 18th-century Irish philosopher, Edmund Burke, become poignant: “All that is necessary for the triumph of evil is that good men do nothing.”

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Name: Peter J. Davis, MD.

Contribution: This author wrote the manuscript.

Attestation: Peter J. Davis approved the final manuscript.

Conflicts of Interest: Peter J. Davis is a section editor for Anesthesia & Analgesia.

This manuscript was handled by: Steven L. Shafer, MD.

a Gaudiosi JA. Child maltreatment 2009. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Retrieved August 29, 2011, from
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1. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high income countries. Lancet 2009; 373: 68–81
2. Harvey S. A different kind of vigilance. Anesth Analg 2012; 114: 910–1
© 2012 International Anesthesia Research Society