98  Social, Ethical and Legal Issues

98.1 Introduction

Social, ethical, and legal considerations are vital components of holistic child healthcare. Understanding the child’s family, social background, and cultural context enables healthcare workers to diagnose and manage effectively. These issues are particularly pertinent in Ghanadue to diverse cultural beliefs, legal mandates, and socio-economic disparities. This chapter explores these themes with real-life illustrations to equip medical students with a broader understanding of child health practice.

98.2 Learning Objectives

By the end of this chapter, students should be able to:

• State the importance of contextualizing patients in family and social history
• Describe the major legal and ethical issues affecting children as patients
• Define child abuse and state the key management issues.
• Describe traditional practices in Ghana that affect children

98.3 The Importance of Social Context in Clinical Practice

Understanding a child’s social context is essential for effective diagnosis and treatment. For example, a child repeatedly brought to the clinic by a grandparent for ‘fever’ might be showing signs of more profound social or emotional distress rather than a physical illness. Medical students must go beyond clinical symptoms and explore the child’s home environment, caregivers, schooling, and socio-economic conditions. Always ask, “Why does THIS child fall sick in THIS way at THIS time?”

98.3.1 Taking a Social History

A good social history is more than just a checklist. It should include thoughtful questions about the child’s living arrangements, primary caregivers, and environmental exposures. Questions might include:

• Who are the child’s primary caregivers?
• Who feeds and bathes the child?
• Where does the child live, and are there known environmental health risks?
• Are there any concerns about school attendance or performance?

Medical students should also assess the reliability of the informant. If the history is provided by someone other than the mother, consider factors such as age, familiarity with the child, and the informant’s mental or physical capacity to provide accurate information.

98.4 Legal and Ethical Considerations in Child Health

Child welfare is a cornerstone of legal and ethical practice in paediatrics. According to Ghana’s Children’s Act (Act 560, 1998), the child’s best interest must always be the paramount consideration in any matter affecting the child.

98.4.1 Key Legal Provisions

• No discrimination based on gender, disability, religion, ethnicity, or socio-economic status.
• Every child has the right to medical care, regardless of parental or religious beliefs.
• Children have a right to education, shelter, nutrition, and protection from abuse.

In practice, clinicians may encounter complex dilemmas, such as parents refusing blood transfusions on religious grounds or the need for a court order involving treatment. In such cases, the principle of the child’s best interest must guide decisions. However, in some cases, the child’s best interest may not be obvious, or there may be more than one child in the situation with interests that do not coincide. An example of this would be where the parents of a child, upon admission, request discharge because another child at home has no one to care for them.

98.5 Child Abuse

Child abuse is defined under the Children’s Act as any contravention of a child’s rights resulting in physical or mental harm. It includes physical, emotional, and sexual abuse, as well as neglect and exploitation.

98.5.1 Recognising Child Abuse

Health workers must be able to recognize signs of abuse, which may include:

• Unexplained injuries
• Multiple injuries at different stages of healing
• Inconsistent explanations from caregivers
• Signs of emotional withdrawal or fearfulness
• Disturbed family dynamics or known parental mental health issues

Medical professionals are legally mandated to report suspected abuse to the Department of Social Welfare. In many cases, health workers may be the only advocates for the child.

98.6 Fosterage and Adoption

98.6.1 Fosterage

Foster parenting involves caring for a child without formal adoption. Any person over 21 years of age with high moral character may be eligible to foster a child. Foster parents are responsible for the child’s welfare, but do not have the same legal rights as adoptive parents.

98.6.2 Adoption

Key regulations around adoption in Ghana include:

• The applicant must be at least 25 years old and 21 years older than the child.
• Single male applicants are generally discouraged except in exceptional circumstances.
• The child must have lived with the applicant for at least three months.
• Adoption is permanent and grants the child full rights, including inheritance.
• Parental consent is required unless the child is abandoned or the parent is deemed unfit.

98.7 Traditional Beliefs and Practices

Cultural beliefs significantly influence health-seeking behaviour in Ghana. Some traditional beliefs can interfere with timely medical intervention.

98.7.1 Common Traditional Concepts

• ‘Asram’: A broad term referring to various childhood illnesses believed to be caused spiritually or through a ‘bad eye’.
• Practices such as squeezing the newborn’s breast to treat engorgement or forcing cord separation can be harmful.
• Other practices like head moulding and the use of herbal amulets may be harmless.
• There are beneficial traditional practices, such as giving newly delivered mothers extra food or the wearing of beads, that help monitor the baby’s growth.

Healthcare providers must acknowledge these beliefs while gently guiding families toward evidence-based practices. Understanding and respecting cultural perspectives can help bridge communication gaps and improve health outcomes.

98.8 Conclusion

Social, ethical, and legal issues are central to paediatric practice. The child must be understood within their social, cultural, and familial context. Accurate social history-taking, sensitivity to cultural practices, and awareness of legal mandates empower medical practitioners to advocate effectively for their young patients. Collaborative efforts with social workers, educators, and legal authorities may be necessary to address complex challenges.